Pancreatic carcinoma

Question 1

Who is most affected by pancreatic carcinoma?

Answer 1

· Median age of diagnosis is 70.

· Median age of death is 72.

Question 2

Most tumours are located in which part of the pancreas?

Answer 2

Head of the pancreas.

Question 3

Distant metastases are usually found in which organs?

Answer 3

Liver, lung, skin and brain.

Question 4

What are the risk factors for pancreatic carcinomas?

Answer 4

· Smoking. 1 in 4 cases of pancreatic cancer can be attributed to cigarette smoking.
· FHx of pancreatic cancer.
· Other hereditary cancer syndromes.

Question 5

List some inherited cancer syndromes associated with pancreatic cancer.

Answer 5

· Hereditary pancreatitis.
· Peutz-Jeghers syndrome.
· Familial atypical multiple mole melanoma.
· Familial breast cancer syndrome.
· Hereditary colorectal cancer syndrome.
· HNPCC / Lynch syndrome.

Question 6

What are the signs and symptoms of pancreatic cancer?

Answer 6

· Jaundice.
· Non-specific upper abdominal pain.
· Weight loss or anorexia.
· Steatorrhoea.

Question 7

What signs might you find upon examination of a patient with suspected pancreatic cancer?

Answer 7

· Hepatomegaly.
· Positive Courvoisier’s sign.
· Petechiae, purpura, bruising.
· Trousseau’s sign.

Question 8

What investigations would you request if you suspected a patient had pancreatic cancer?

Answer 8

· Abdominal USS.
· Pancreatic protocol CT.
· LFT's.
· Prothrombin time.
· FBC.
· Cancer Antigen (CA)19-9 biomarker.
· PET scan.

Question 9

Suggest some differential diagnoses.

Answer 9

· Chronic pancreatitis. 
· Bile duct stones. 
· Ampullary carcinoma. 
· Cholangiocarcinoma. 
· Autoimmune pancreatitis.

Question 10

What is the treatment option for a patient who has a resectable tumour in stages I and II?

Answer 10

· 1st line - Surgical resection.
· Plus - Pancreatic enzyme replacement.
· Adjunct - Pre-operative biliary stenting.
· Adjunct - Neoadjuvant radiotherapy or chemoradiotherapy.
· PLUS - If completely resected - Adjuvant chemotherapy.
· ADJUNCT - If incompletely resected - Adjuvant chemoradiotherapy.

Question 11

What is the treatment option for a patient who has a locally advanced unresectable tumour in stage III?

Answer 11

· 1st line - Endoscopic stent insertion or palliative surgery.
· Plus - Chemotherapy or Chemoradiotherapy or Stereotactic body radiotherapy.
· Plus - Pain management + Pancreatic enzyme replacement.

Question 12

What is the treatment option for a patient who has a metastatic tumour in stage IV?

Answer 12

· 1st line - Endoscopic stent insertion or palliative surgery.
· Plus - Chemotherapy.
· Plus - Pain management + Pancreatic enzyme replacement.

Question 13

What complications can occur?

Answer 13

· Surgical complications:

• Pancreatic leak and fistula.
• Early delayed gastric emptying.

· Non-surgical complications:

• Duodenal obstruction.
• Cholangitis.
• DVT and PE.
• Bleeding.