Pancreatic Ca

• Pancreatic cancer is often diagnosed late and has a very poor prognosis

  The vast majority are adenocarcinomas and occur in the head of the pancreas
• Courvoisier's law = a painless palpably enlarged gallbladder accompanied with jaundice is unlikely to be caused by gallstones

  Likely to be pancreatic cancer
• Risk factors:

  · Smoking

  · Diabetes

  · Chronic pancreatitis or inflammation of the pancreas

  · Family history
• Once a tumour in the head of the pancreas grows large enough it can compress the bile ducts, resulting in obstructive jaundice.
• Painless obstructive jaundice is a key presenting feature that should make you immediately consider pancreatic cancer (the key differential is cholangiocarcinoma). This occurs when a tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver. It presents with:

  • Yellow skin and sclera
  • Pale stools
  • Dark urine
  • Generalised itching
• The other presenting features for pancreatic cancer can be vague:

  • Non-specific upper abdominal or back pain
  • Unintentional weight loss
  • Palpable mass in the epigastric region
  • Change in bowel habit
  • Nausea or vomiting
  • New-onset diabetes or worsening of type 2 diabetes
• NICE guidlines on referral for suspected cancer:

  • Over 40 with jaundice - 2WW referral
  • Over 60 with weight loss plus:
  • Diarrhoea
  • Back pain
  • Abdominal pain
  • Nausea
  • Vomiting
  • Constipation
  • New-onset diabetes
  • For direct access CT abdomen
• CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions.
• Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.
• In most cases, curative surgery is not possible. Palliative treatment may involve:

  • Stents inserted to relieve the biliary obstruction
  • Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
  • Palliative chemotherapy (to improve symptoms and extend life)
  • Palliative radiotherapy (to improve symptoms and extend life)
  • End of life care with symptom control
• A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the:

  • Head of the pancreas
  • Pylorus of the stomach
  • Duodenum
  • Gallbladder
  • Bile duct
  • Relevant lymph nodes