The Pancreas - Carcinoma of the Pancreas

Question 1

Pathophysiology of Pancreatic Cancer (3).

Answer 1

1. Majority - Adenocarcinomas (glandular duct cells that line the ducts of the exocrine system).
2. Occur in the head of the pancreas (not body/tail).
3. It can grow large enough to compress the bile ducts, resulting in obstructive jaundice.

Question 2

Risk Factors of Pancreatic Cancer (6).

Answer 2

1. Increasing Age.
2. Smoking.
3. Diabetes.
4. Chronic Pancreatitis.
5. HNPCC, MEN.
6. BRCA2 Gene Mutation and KRAS Gene Mutation.

Question 3

Clinical Presentation of Pancreatic Cancer (6).

Answer 3

1. PAINLESS OBSTRUCTIVE JAUNDICE.
2. Non-Specific Upper Abdominal/Atypical Back Pain.
3. Constitutional Symptoms.
4. Palpable Mass in Epigastric Region.
5. Change in Bowel Habit, Nausea and Vomiting.
6. New-Onset Diabetes/Worsening of Type 2 Diabetes.

Question 4

Why does Pancreatic Cancer cause painless obstructive jaundice?

Answer 4

The tumour at the head of the pancreas compresses the bile ducts, to block the flow of bile out of the liver.

Question 5

Clinical Features of Painless Obstructive Jaundice (4).

Answer 5

1. Yellow Skin and Sclera.
2. Pale Stools.
3. Dark Urine.
4. Generalised Itching.

Question 6

Relevant Signs in Pancreatic Cancer (2).

Answer 6

1. Courvoisier’s Law : A Palpable Gallbladder with Jaundice is unlikely due to gallstones - either Cholangiocarcinoma or Pancreatic Cancer.
2. Trousseau’s Sign of Malignancy : Migratory (different locations over time) Thrombophlebitis (blood vessels become inflamed with an associated thrombus) - usually associated with malignancy, especially pancreatic adenocarcinomas.

Question 7

Investigations in Pancreatic Cancer (5).

Answer 7

1. Diagnosis - Imaging (CT) + Histology-Biopsy (Percutaneous US/CT-Guided or ERCP).
2. Staging - CT TAP.
3. CA19-9 (Carbohydrate Antigen) : Tumour Marker.
4. MRCP - Biliary System Assessment.
5. LFTs : Cholestatic.

Question 8

What can Imaging show in Pancreatic Cancer?

Answer 8

Double Duct Sign - presence of simultaneous dilation of the common bile duct and pancreatic ducts.

Question 9

Referral Criteria for Pancreatic Cancer (2).

Answer 9

1. Over 40 with Jaundice - 2 WEEK WAIT.
2. Over 60 with Weight Loss + Another Symptom - Direct Access CT Abdomen.
   (Symptoms : Diarrhoea, Pain/Abdominal Pain, Nausea, Vomiting, Constipation, New-Onset Diabetes).
   * This is the only time a GP can refer a patient directly to a CT scan.

Question 10

Management of Pancreatic Cancer (3).

Answer 10

1. HPB (Hepatobiliary) MDT Meeting.
2. Surgery : if small tumour, isolated in head of pancreas.
3. MOSTLY Palliative : Chemotherapy, Radiotherapy, Surgery to Improve Symptoms e.g. Bypass Biliary Obstruction, Stents Insertion.

Question 11

Surgery in Pancreatic Cancer (4).

Answer 11

1. Total Pancreatectomy.
2. Distal Pancreatectomy.
3. Pylorus-Preserving Pancreaticoduodenectomy (Modified Whipple procedure).
4. Radical Pancreaticoduodenectomy (Whipple procedure).

Question 12

What does a Whipple procedure involve?

Answer 12

Removal of the head of the pancreas, gallbladder, bile duct, pylorus of the stomach, duodenum and relevant lymph nodes.

Question 13

What does a modified Whipple procedure involve?

Answer 13

Leaving the pylorus in place.

Question 14

Complications of Whipple’s Procedure.

Answer 14

1. Dumping Syndrome.
2. Peptic Ulcer Disease.

Question 15

Prognosis of Pancreatic Cancer (2).

Answer 15

1. Often diagnosed late and poor prognosis.
2. Metastasise early (liver –> peritoneum –> lungs –> bones).