Pancreatic Carcinoma

Question 1

Histology and location

Answer 1

Most are adenocarcinoma occuring in head of pancreas

Question 2

What happens when tumour of pancreas head grows large enough

Answer 2

Obstructs bile ducts causing obstructive jaundice

Question 3

PROGNOSIS

General

Answer 3

Often diagnosed late and very poor prognosis

Question 4

Where does normally spread to

Answer 4

• Liver, then to peritoneum, lungs and bones

Question 5

CLINICAL FEATURES

Presentation

Answer 5

• Painless obstructive jaundice key presentation
• Other presenting features can be vague
  
  • Non-specific upper abdominal or back pain
  • Weight loss
  • Palpable mass in epigastric region
  • Change in bowel habit
  • Nausea or vomiting
  • New-onset diabetes or worsening T2

Question 6

Referal guidance

Answer 6

• Over 40 with jaundice - 2 week wait referal
• Over 60 with weight loss plus additional symptom - direct access CT abdomen
  
  • Diarrhoea
  • Back pain
  • Abdominal pain
  • Nausea
  • Vomiting
  • Constipation
  • New‑onset diabetes

Question 7

What does Courvoisier’s law state

Answer 7

Palpable gallbladder along with jaundice is unlikely to be gallstones

Cause is usually cholangiocarcinoma or pancreatic cancer

Question 8

What is Trousseau’s sign of malignancy

Answer 8

Refers to migatory (reocurring in different locations) thrombophlebitis, its a sign of malignancy - particularly pancreatic adenocarcinoma

Question 9

What is thrombophlebitis

Answer 9

Blood vessels become inflammed with an associated thrombus

Question 10

INVESTIGATIONS

First choice

Answer 10

• Diagnosis based on imaging (usually CT scan) plus histology from biopsy
  
  • Staging CT scan - CTTAP (thorax, abdomen and pelvis)
  • MRCP - maybe to assess biliary obstruction
  • ERCP - maybe to stent biliary obstruction
  • Biopsy under US or CT guide or during endoscopy under US guidance

Question 11

MANAGEMENT

General principles

Answer 11

• Management decided at hepatobiliary MDT meeting
• Surgery to remove tumour most likely if small tumour head of pancreas
• Palliative treatment in most cases

Question 12

MANAGEMENT

Surgical options

Answer 12

• Total pancreatectomy
• Distal pancreatectomy
• Pylorus-preserving pancreaticoduodenectomy (PPPD - modified Whipples procedure
• Radial pancreaticoduodenectomy (Whipple procedure)

Question 13

MANAGEMENT

Palliative treatment

Answer 13

• Stens to relieve biliary obstruction
• Surgery to improve obstruction
• Palliative chemotherapy
• Palliative radiotherapy
• End of life care and symptom control

Question 14

What is Whipples procedure

Answer 14

• Surgical procedure to remove tumour of head of pancreas that has not spread, removal of
  
  • Head of pancreas
  • Pylorus of stomach
  • Duodenum
  • Gallbladder
  • Bile duct
  • Relevant lymph nodes

Question 15

What is modified Whipple procedure

Answer 15

• Same, but the pylorus is left in place

Question 16

AETIOLOGY

Risk factor

Answer 16

• Smoking
• FH
• Hereditory cancer syndromes