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