Pancreatic cancers

• Pancreatic cancers


  PDAC and NET
• Pancreatic ductal adenocarcinoma (PDAC)


  • 95% of pancreatic tumors are adenocarcinomas
  • Accounts for 3% of new cancer cases per annum
  • 4th leading cause of cancer-related death in Western countries
  • Insidious nature and vagueness of presentation contribute to late diagnosis
  • Overall 5 year survival remains 6%
  • Peak incidence between 7th and 8th decade
  • Rare under the age of 30
  • Pancreatic cancer must be detected at an early stage to enable potential for curative treatment
• Risk factors and pre-malignant conditions

  • IPMN and MCN
• Presentation


  • Majority of patients present with vague, non-specific symptoms
  • Disease commonly widespread at diagnosis – 80% have unresectable disease at presentation
  • Early satiety
  • Obstructive jaundice
  • Unexplained weight loss
  • Endoscopy negative epigastric/back pain
  • Late-onset diabetes
  • Signs of malabsorption without defined cause
• Investigations


  • Blood tests
  • Imaging studies
• Blood tests


  • May have normocytic, normochromic anemia
  • Elevated serum bilirubin and ALP may confirm obstructive jaundice
  • Tumor markers - No ideal marker, CA 19-9 elevated in 50%, Sensitivity 81-85% and specificity 81-90% in symptomatic patients, Low positive predictive value in asymptomatic patients, Falsely elevated in other neoplasms as well as benign conditions
• Imaging studies


  • Ultrasound – 95% sensitivity in lesions > 3cm
  • Contrast-enhanced abdominal CT –most common staging modality. (Pancreas protocol CT scan), Sensitivity > 90% in lesions > than 2 cm, Allows for assessment of primary lesion and relationship to remainder of pancreas and peripancreatic vasculature, Determine resectability
  • MRI/MRCP
  • Endoscopic ultrasound
  • (PET-CT scanners)
• Management approach


  1. Exclude red flags at presentation: most common cholangitis & pruritis

  2. Confirm and stage of tumor: pCTAP

  3. Discuss at a multidisciplinary meeting

  4. Resectable: consider resection, ?need to drain jaundice

  5. Borderline resectable: drain jaundice, neo-adjuvant chemotherapy

  6. Not resectable or metastatic: palliate
• Radiology


  • Abdominal ultrasound
  • Pancreas protocol CTAP
  • Tumor extension
  • Relationship with SMV-PV and SMA
  • Exclude metastatic disease
  • Operability
• Resection


  • Lesions in the head of the pancreas resected by pancreaticoduodenectomy
  • Lesions in the body and tail of the pancreas resected by distal pancreatectomy plus splenectomy
• Resection


  • Only potential for cure
  • Patient selection is paramount, including cardiovascular and respiratory evaluation
  • Surgery with curative intent is associated with 10-18% alive at 5 years
  • Mortality rates from pancreticoduodenectomy < 5%
  • Morbidity rates from pancreticoduodenectomy 30-50%
  • Type of surgery depends on location of tumor in the pancreas
• Adjuvant therapies


  • Chemotherapy: Gemcitabine or 5-fluorouracil, Newer regimens showing improved response rates but increased toxicity such as FOLFIRINOX, Despite role of adjuvant therapy, survival remains poor
  • Role of radiotherapy not well established in pancreatic cancer
• Palliation


  1. Mostly centered around relieving obstructive jaundice, addressing gastric outlet obstruction and improving pain

  2. The first two options can be addressed endoscopically or surgically

  3. Pain treated using a step approach as advocated by WHO

  4. Patients may benefit from coeliac axis neurolysis which can be performed via endoscopic ultrasound, at time of surgery or percutaneously
• Pancreatic neuroendocrine tumors (PNET)


  • Rare tumors with reported incidence of 0.2-0.4 per 100000
  • 85% non-functional
  • Of the functional PNETs carcinoid, insulinoma and gastrinoma are the most common
  • Etiology is poorly understood and although majority are sporadic, there are associations with several hereditary syndromes, such as Von Hippel-Lindau and multiple endocrine neoplasis-1 (MEN-1)