Pancreatic Carcinoma

Introduction

Pancreatic carcinoma is the 5^th most common cancer in the UK. Most are adenocarcinomas.

Epidemiology

Affects 10 in 100,000.

Age: 80% of patients are 60 to 80 years old

Sex: Males are affected more than females

Risk factors

• Smoking
• Fatty diet
• Chronic pancreatitis
• Diabetes
• Genetic predisposition e.g. hereditary pancreatitis, multiple endocrine neoplasia, HNPCC

Pathophysiology

90% are pancreatic carcinomas are adenocarcinomas. Other types include neuroendocrine tumours, such as insulinomas and glucagonomas.

It may affect:

• Head of the pancreas (60%) – usually presents with obstructive jaundice
• Body of the pancreas (15%)
• Tail of the pancreas (5%) – usually endocrine
• Diffuse (20%)

Clinical features

Clinical features depend on which part of the pancreas is cancerous. 50% of cases present with jaundice that is usually painless. Abdominal pain, weight loss and malaise occur with advanced disease. The symptomatic course is usually brief and progressive.

Tumour of head and ampulla of Vater

• Bile duct obstruction – jaundice, pruritus
• Pancreatitis
• Weight loss

Signs may include:

• Jaundice
• Palpable gallbladder (Courvoisier’s sign)
• Thrombophlebitis migrans (Trousseau sign)

Pain usually begins when there is invasion of the coeliac plexus; the pain is incessant and present in the upper abdomen with radiation to the back and can be relieved by leaning forwards.

Tumour of body or tail

• Abdominal pain – dull; upper abdomen radiating to back; relieved by leaning forwards
• Weight loss

Biliary obstruction and weight loss are late features.

Investigations

LFTs may show obstructive jaundice (raised bilirubin and ALP>ALT). The diagnosis can be confirmed on ultrasound imaging and contrast-enhanced CT.

Management

Surgical resection is the only curative therapy available, although only 20% of patients are eligible as most have had disease spread at the time of diagnosis. Whipple’s resection is the preferred surgical operation.

Otherwise, palliative therapies can be offered to relieve biliary obstruction, which include stenting using ERCP or a bypass procedures (e.g. anastomosing jejunum and hepatic duct)

Whipple’s resection

Pancreaticoduodenectomy involves removal of the:

• Head of the pancreas
• Distal stomach
• Duodenum
• Gallbladder
• Bile duct

Intestinal continuity can the be restored by anastomosing the remaining structures. Note that this procedure cannot be used to treat tumours involving the tail of the pancreas.

Prognosis

Prognosis is very poor. 5-year survival with resection is 12%. Tumours of the body and tail of the pancreas have a worse prognosis

Less than 20% of tumours are resectable are the time of diagnosis.