Pancreatic Cancer

Background

  • Pancreatic cancer is the second most common tumour of the digestive tract
    • Most occur in 70-90 year old patients
    • It has a very poor prognosis
      • overall 5-year survival remains <5%
      • It is the 5th most common cause of cancer death (6% of cancer deaths) despite being the 11th most common cancer
      • 98% of pancreatic cancer is metastatic and over half present with metastatic disease at diagnosis
  • More common in males (2:1)
  • Most are adenocarcinomas (90%) and most pancreatic cancers arise from the pancreas itself and 10% arise from the distal common bile duct
    • 75% in the head/neck; 15-20% in the body and 5-10% in the tail
Aetiology
  • NB 40% are sporadic
  • Smoking
  • Alcohol is not necessarily a risk factor unless it is associated with chronic pancreatitis
  • Chronic pancreatitis
  • Diabetes mellitus in patients over 50
  • Obesity
  • Genetic factors
    • KRAS2 gene; p53
    • Familial cancer syndromes e.g. BRCA; MEN
Presentation
  • Early symptoms are often vague and non-specific
    • Epigastric pain and/or back pain (often dull and achey)
    • Often worse lying down- can be nocturnal and awakening
  • Anorexia and weight loss
  • Nausea
  • Obstructive jaundice may present early if the tumour arises in the common bile duct/head of the pancreas but may be a late sign or a sign of metastatic disease if the tumour is from the body/tail
    • Painless
    • NB Ascites is a late sign
  • Acute/subacute pancreatitis
    • Steatorrhea
  • Features of metastases e.g. SOB, jaundice, bone pain etc
  • Abdominal masses are uncommon and are often a late sign
Investigations
  • Blood tests
    • FBC- normochromic anaemia, thrombocytosis
    • LFTs- deranged either due to obstruction (bilirubin and ALP) but also raised AST/gGT (particularly in metastatic disease)
    • Hyperglycaemia
    • CA19-9
      • 80% sensitivity and 73% specificity
      • most useful in assessing response to treatment
  • Imaging
    • USS is usually first line
    • CT is preferred and is most useful in staging (see below)
      • MRI and PET may add to staging process
    • Endoscopic USS
Staging
  1.  
    • A- T1 (<2cm; restricted to the pancreas); N0; M0.
    • B- T2 (>2cm; restricted to the pancreas); N0; M0
    • A- T3 (extending into adjacent structures); N0; M0
    • B- T1-3; N1 (nearby lymph node involvement); M0
  2. T4 (grown into nearby blood vessels); N1-2; M0
  3. T1-4; N1-2; M1 (distant disease)
  • Most (47.5%) patients present at stage 4
  • Resectable disease is rare- stages 1-2- and account for only 15% of cases at presentation
Management
  • All management should be decided in a MDT meeting with oncology, surgery, and palliative care.
  • Surgery
    • Only chance of cure (but only suitable in 15% of patients)
    • Different kinds of surgery depending on the location/extent of the tumour
      • Whipple’s procedure (for pancreatic head/neck cancers)
        • Proximal pancreaticoduodenectomy with antrectomy
          • Involves resecting the proximal pancreas, duodenum and antrum of the stomach and joining the hepatobiliary duct, pancreatic duct and stomach to the jejunum
        • Ocreotide must be given one week after to reduce pancreatic secretions
      • Modified Whipple’s procedure (preserves the gastric antrum and pyloric sphincter to maintain gastric emptying)
        • No increase in 5-year mortality compared to Whipple’s, less morbidity
      • Distal pancreatectomy (for body/tail tumours)
      • NB Total pancreatectomy is rarely done
    • Even successful resections have only a 15-20% 5 year survival (mean 12-19 months)
  • Chemotherapy
    • Usually resistant but may be used adjuvantly/palliatively for increased chance of survival or improvement of symptoms (respectively)
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