Pancreatic cancer 

epidemiology

• fifth most common cause of cancer death
• African descent at increased risk
• male:female = 1.7:1
• age (average 50-70)

risk factors

• increased age
• smoking – 2-5x increased risk, most clearly established risk factor
• high fat/low fibre diets
• chronic pancreatitis
• diabetes
• heavy alcohol use
• chemical: betanaphthylamine, benzidine
• Obesity with Body Mass Index (BMI) >30 kg/m2
• BRCA1 gene carrier

clinical presentation is related to location of tumour

• Red flags
  •     New onset Type II Diabetes Mellitus in a thin patient over age 50 years old
  •     Recurring Superficial Thrombophlebitis
• head of the pancreas (70%)
  • weight loss
  • obstructive jaundice
  • abdominal pain – dull ache in midepigastrium, progressive, often worse at night, may radiate to back
  • painless jaundice occurs more often with ampullary or primary bile duct tumours, and is not common in pancreatic cancers
  • palpable tumour mass = incurable
• carcinoma of body or tail of pancreas (30%)
  • tends to present later and usually inoperable
  • < 10% jaundiced
  • weight loss, vague midepigastric pain
  • sudden onset diabetes mellitus

• surgical dictum:
  • vague abdominal pain with weight loss +/– jaundice in a patient
• 50 years old is pancreatic cancer until proven otherwise

Signs

• Non-specific findings
  • Cachectic patient
  • Bruising
  • Jaundice (if biliary duct obstruction)
• Courvoisier’s Sign
  • Non-tender, but distended, palpable Gall Bladder
  • Associated with Jaundice
  • Test Sensitivity only <56%, but Test Specificity >82%
• Other findings
  • Left Supraclavicular Lymphadenopathy involving Virchow’s Node
  • Subcutaneous Nodules of fat or pancreatitic Panniculitis (rare)

diagnosis

• serum chemistry non-specific: elevated ALP and bilirubin (>18)
• evidence of obstruction: U/S, CT – evaluation of metastasis
• Most accurate testing
  • Triple-phase helical CT with Pancreas protocol (preferred) – Includes imaging during arterial, late and venous phases
  • Endoscopic Ultrasound- Indicated if helical CT not diagnostic or for biposyM Guides FNA in non-operable cancer
• Tumor Markers
  • CA 19-9 (use for diagnosis/prognosis, NOT screening)
  • bHCG (better prognostic indicator than CA 19-9)
  • CA 72-4 (better prognostic indicator than CA 19-9)

pathology

• ductal adenocarcinoma – most common type (75-80%)
• giant cell carcinoma (4%)
• adenosquamous carcinoma (3%)
• other: mucinous, cystadenocarcinoma, acinar cell carcinoma

• spread
  • early to local lymph nodes and liver

treatment

• operable (i.e. no metastases outside abdomen, liver, or peritoneal structures, and no involvement of hepatic artery, superior mesenteric artery, portal vein at body of pancreas)
  • 20% of head of pancreas cancers can be resected
  • Whipple’s procedure (pancreatoduodenectomy) for cure – 5% mortality (see Figure 14)
  • distal pancreatectomy +/– splenectomy, lymphadenectomy if carcinoma of midbody and tail of pancreas

prognosis

• average survival – 7 months
• 5 year survival is 10%
• following Whipple’s procedure, mean survival – 18 months
• most important prognostic indicator is lymph node status