Carcinoma of the pancreas

Incidence - 9 per 100,000
- now the 5th most common cause of cancer death in the US and UK

Age - most patients are over 60
- incidence increases with age

Sex - M > F

Geography

Aetiology
- smoking and diet rich in red meat and cholesterol?
- alcohol and coffee are probably not causes
- exposure to petroleum products?
- diets high in fibre and vitamin C are probably protective

- 90% are adenocarcinomas arising from duct epithelium
- neuroendocrine and acinar cell carcinomas
- tumour is in head of pancreas in 70% of cases

- K-Ras mutations and high levels of p53 gene expression are common

Presentation
CA of head of pancreas / ampulla of vater:
- painless jaundice
- anorexia, weight loss and pain occur later in disease
- on examination; jaundiced with dilated gallbladder occasionally palpable (Courvoisier's sign)

Carcinoma of body or tail of pancreas:
- abdominal pain; dull, "boring", radiates through to back. May be relieved by sitting forward.
- anorexia
- weight loss
- jaundice is rare
- diabetes in about 15% of cases; insulin resistance dur to islet amyloid polypeptide
- increased incidence of thrombophlebitis

- palpable mass in 20%
- hepatomegaly develops in most eventually

Differential
- all causes of painless jaundice and persistent upper abdominal pain in the elderly

Investigations

Macro

Micro

Staging - local spread to duodenum, peritoneum, liver, spleen

Serum markers - tumour markers include CEA, CA 19.9, CA 242
- use is discouraged due to false positives and negatives

Management
Palliation
- jaundice is relieved by a bypass procedure, e.g. endoscopic stenting; improves QOL
- if tumour has obstructed duodenum, surgical bypass linking the CBD to the jejunum can be performed
- chemotherapy and radiotherapy do little to reduce mortality
- manage anxiety and depression
- analgesia with long-acting oral morphines
- palliative care team approach

Surgical
- pancreatic duodenectomy in selected cases

Prognosis
- 5 year survival is 2%
- most survive less than 1 year from diagnosis
- pancreatic-duodenectomy has a 5-year survival of 10-20%; this is only in the 10% of patients with tumours < 3cm in diameter and no local spread
- operative mortality is 5%, 30-40% morbidity - patients should be carefully selected

- ampullary tumours have a better prognosis if found and resected; 5 year survival is 40%

Complications

Hepatobiliary medicine

Main Page

Incidence	- 9 per 100,000 - now the 5th most common cause of cancer death in the US and UK
Age	- most patients are over 60 - incidence increases with age
Sex	- M > F
Geography
Aetiology	- smoking and diet rich in red meat and cholesterol? - alcohol and coffee are probably not causes - exposure to petroleum products? - diets high in fibre and vitamin C are probably protective - 90% are adenocarcinomas arising from duct epithelium - neuroendocrine and acinar cell carcinomas - tumour is in head of pancreas in 70% of cases - K-Ras mutations and high levels of p53 gene expression are common
Presentation	CA of head of pancreas / ampulla of vater: - painless jaundice - anorexia, weight loss and pain occur later in disease - on examination; jaundiced with dilated gallbladder occasionally palpable (Courvoisier's sign) Carcinoma of body or tail of pancreas: - abdominal pain; dull, "boring", radiates through to back. May be relieved by sitting forward. - anorexia - weight loss - jaundice is rare - diabetes in about 15% of cases; insulin resistance dur to islet amyloid polypeptide - increased incidence of thrombophlebitis - palpable mass in 20% - hepatomegaly develops in most eventually Differential - all causes of painless jaundice and persistent upper abdominal pain in the elderly
Investigations
Macro
Micro
Staging	- local spread to duodenum, peritoneum, liver, spleen
Serum markers	- tumour markers include CEA, CA 19.9, CA 242 - use is discouraged due to false positives and negatives
Management	Palliation - jaundice is relieved by a bypass procedure, e.g. endoscopic stenting; improves QOL - if tumour has obstructed duodenum, surgical bypass linking the CBD to the jejunum can be performed - chemotherapy and radiotherapy do little to reduce mortality - manage anxiety and depression - analgesia with long-acting oral morphines - palliative care team approach Surgical - pancreatic duodenectomy in selected cases
Prognosis	- 5 year survival is 2% - most survive less than 1 year from diagnosis - pancreatic-duodenectomy has a 5-year survival of 10-20%; this is only in the 10% of patients with tumours < 3cm in diameter and no local spread - operative mortality is 5%, 30-40% morbidity - patients should be carefully selected - ampullary tumours have a better prognosis if found and resected; 5 year survival is 40%
Complications