Pancreatic carcinoma Flashcards
Are majority of pancreatic cancers exocrine or endocrine in origin?
Exocrine (90%)
At what age is diagnosis of pancreatic cancer made?
Does it affect men or women more?
Diagnosis made in 70’s ; late presenting
Men>women
What type of pancreatic cancer is most common?
Adenocarcinoma (96%) of ductal origin
What are the risk factors of pancreatic cancer?
Smoking Excess alcohol Excess coffee Excess aspirin Hx of diabetes & chronic pancreatitis Family Hx of pancreatic cancer
*Risk of pancreatic cancer highest in patients with a (PRSS1) mutation predisposing to chronic pancreatitis.
Which tissue does pancreatic cancer arise from?
How does it evolve from pre-malignant to cancerous tissue?
The cancer originates from the ductal epithelium.
Progression:
Minimally dysplastic epithelium => Severe dysplasia => invasive carcinoma
What is the term given to the precursor of pancreatic cancer?
Pancreatic intraepithelial neoplasia
What’s the most common mutation in pancreatic cancer?
> 90% cases KRAS mutations
Anatomically, where do you commonly find tumours on a pancreas?
Head of the pancreas
2/3 of pancreatic cancer here
What are the clinical features of pancreatic cancer?
Abdominal pain ; radiates to back ; partially relieved by sitting forward
Anorexia & weight loss
New onset of depressive symptoms (early symptom)
(Painless) Jaundice (compression of distal common bile duct)
Pale stool, dark urine & itching with bile duct obstruction prior to/in absence of jaundice
Malabsorption and steatorrhoea
Diabetes (50%)
Less common:
Skin nodules
Polyarthritis
Thromboembolic phenomena
What are the signs of pancreatic cancer?
Weight loss Jaundice Scratch marks - pruritus Palpable gall bladder (Courvoisier's sign) Abdominal mass - advanced local disease Liver mets - hepatomegaly
How do you diagnose pancreatic cancer?
- Trans-abdominal ultrasound (initial imaging investigation):
Confirms dilated intra-hepatic bile duct in the presence of bile duct obstruction
Confirms pancreatic head tumour
Not good for pancreas body & tail tumours because of overlying bowel gas
- Contrast-enhanced CT scan:
Confirms the presence of most pancreatic adenocarcinoma
Confirms lymph node involvement & metastatic disease (used for diagnosis + staging) - Endoscope ultrasound:
Small tumours which may be missed on CT
Confirms cytology
(Most sensitive non-surgical procedure) - Tumour markers
Patients with pancreatic cancer present at late stage
Upper gut symptoms in these patients first prompt for upper GI endoscopy
What are the differential diagnosis for pancreatic cancer?
In presence of painless jaundice or pain radiating to back => always think pancreatic cancer first
Auto-immune pancreatitis ;
Abdominal aortic aneurysm ;
Ampullary carcinoma
How do you treat curative pancreatic cancer?
Curative treatment: Whipple procedure (aka pancreaticoduodenectomy, is a complex operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct).
Tumours of body and tail resected via laparoscopic surgery.
Chemotherapy neo/adjuvant (Gemcitabine, fluorouracil) may improve survival
How do you manage non-curative pancreatic cancer?
Palliative care - managing complications of pancreatic cancer
Pain: opiates
Nutritional deficit: Dietician support, pancreatic enzyme supplement (due to malabsorption), management of diabetes
Obstructive jaundice: assoc with anorexia, nausea and pruritus => endoscopic stenting improves this
Duodenal obstruction: endoscopic stenting (assoc. with tumours in head or uncinate process of pancreas)
Chemotherapy: may exacerbate nutritional deficit
What is the prognosis of pancreatic cancer?
Very poor. Mean survival <6 months. 5yr survival 3% ; 5-14% with whipple’s