Table Of Contents
Pancreatic Tumours
Pancreatic tumours originate from either the exocrine pancreas or the endocrine pancreas (pancreatic neuroendocrine tumours – PNET). 95% of pancreatic tumours are exocrine tumours, most commonly adenocarcinoma.
Pancreatic cancer is the tenth most common cancer and the fourth most common cause of cancer death. It accounts for 2 – 3% of cancers worldwide. It has a peak incidence at 65 – 75 years old. More than 90% of pancreatic tumours have a KRAS mutation. 5-year survival is around 25% or less.
Eponyms associated with pancreatic cancer
| Eponym | Description |
|---|---|
| Courvoisier’s law | In the presence of painless jaundice a palpable gallbladder is more likely to be a neoplasm e.g. pancreatic cancer than due to gallstones |
| Trousseau’s sign (migratory thrombophelbiits) | Inflammation and thrombosis (thrombophelibitis) occurring in different locations. Rare |
Clinical features of advanced pancreatic cancer
| Clinical features | Description |
|---|---|
| Pulmonary emboli | Shortness of breath and chest pain May be due to pulmonary metastases or thrombo-emboli (Trousseau’s syndrome) |
| Diabetes mellitus | New-onset diabetes or rapid worsening of glycaemic control of type 2 diabetes maybe a sign of pancreatic cancer. |
| Ascites | May be due to liver metastases or peritoneal carcinomatosis. May also see hepatomegaly and hypoalbuminaemia. |
Pancreatic neuroendocrine tumours (PNET)
| Tumour | Description | Common locations |
|---|---|---|
| Insulinoma | Most common Presents with whipple triad. Most common functional PNET. Most likely to be benign. | Anywhere in the pancreas |
| Gastrinoma | Zollinger-ellison syndrome. Occurs in the gastrin. Most associated with MEN syndrome. | Gastrinoma triangle |
| VIPoma | Watery diarrhoa, hypokalemia and achlorrhydria. | Body and tail of pancreas |
| Glucagonoma | 4 Ds: dermatitis (necrolytic migratory erythema), diabetes, DVT, depression | Tail |
| Somatostatinoma | Diabetes, steatorrhoea, cholelithiasis | Duodenum and head of pancreas |
| Non-functional | Most common PNET. Local symptoms, Elevated chromogranin A, neurotensi, or pancreatic polypeptide | Head of pancreas |
Pancretic exocrine tumours
| Tumour | Description |
|---|---|
| Pancreatic adenocarcinoma | Arises from non-invasive pancreatic intraepithelial neoplasms (PanINs). May have elevated CA 19-9 (75%( |
| Cystic neoplasms | Includes serouc systic neoplasm (SCNs), mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs). Thick mucus extruding from the ampulla at ERCP is diagnostic of main duct IPMN |
- Risk factors for pancreatic cancer
- Age > 60 years
- Male gender
- African ethnicity
- Cigarette smoking
- Diabetes mellitus
- Partial gastrectomy
- Family history of pancreatic cancer (including germline BRCA2 mutation)
- Hereditary pancreatitis
- Chronic pancreatitis (with the risk factors of alcohol and gallstones indirectly)
- Lunch syndrome (HNPCC)
- Ataxia telangiectasia
- Peutz-Jeghers syndrome
- Familial breast-ovarian cancer syndrome
- Familial atypical multiple mole melanoma
- Familial adenomatous polyposis (FAP has a risk of ampullary/duodenal carcinoma)
- Metastasis
- Direct spread
- Hematogenous spread
- Lymphatic system
- Transceolomic (peritoneal seeding)
- Signs and symptoms
- Epigastric pain
- Vague discomfort
- Radiating to the back
- Jaundice
- Progressive
- Pruritus
- Dark urine
- Pale stool
- Steatorrhoea
- Anorexia
- Weight loss
- Back pain (retroperitoneal infiltration)
- Epigastric pain
- Physical examination
- Cachetic
- Jaundice
- Epigastric mass (hepatomegally or gallbladder)
- Ascites
- Investigations
- Staging CT scan (CT thorax, abdomen and pelvis – CT TAP): best initial test. To look for metastasis and other causes
- Magnetic resonance cholangio-pancreatography (MRCP): to assess the biliary system in detail and to assess the obstruction
- Endoscopic retrograde cholangiopancreatography (ERCP): can be used to stent the biliary tree in case of obstruction and obtain a biopsy
- Endoscopic ultrasound: useful if CT fails to demonstrate tumour. Can also be used to obtain a biopsy
- Diagnostic laparosocpy: to evaluate peritoneal and liver metastases
- CA 19-19: a carbohydrate antigen used as a tumour marker that may be raised in pancreatic cancer and cholangiocarcinoma
- Surgical treatment
- Total pancreatectomy
- Distal pancreatectomy
- Radical pancreaticoduodenectomy (Whipple procedure): removal of the head of the pancreas, pylorus of stomach, duodenum, gallbladder, bile duct, and local lymph nodes
- Pylorus-preserving pancreaticoduodenectomy (PPPD – modified Whipple procedure): the pylorus is left in place
- Contraindications to surgical resection of the pancreas
- Hepatic or peritoneal metastases (may be represented with ascites)
- Lymph node metastases distant from the pancreatic head
- Encasement of the superior mesenteric, hepatic or coeliac artery
Palliaitve treatment of pancreatic cancer
| Component | Intervention |
|---|---|
| Relieve jaundice and treat biliary sepsis | Biliary bypass (choledochoenterostomy), stenting |
| Improve gastric emptying | Gastreoenterostomy, duodenal stent |
| Pain relief | Analgesia, coeliac plexus block, transthoracic splanchnicectomy |
| Quality of life | Encourage normal activityes, enzyme replacement for steatorrhoea, treat diabetes |
| Chemotherapy | Consider chemotherapy |
