Pancreatic Cancer

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💡 Pancreatic cancer is notoriously difficult to diagnose early due to its deep location and vague symptoms. 🚨 A normal ultrasound (USS) does not exclude pancreatic cancer. ⚠️ Periampullary lesions may present earlier with obstructive jaundice.

📖 About

• Most patients present with advanced, incurable disease.
• Periampullary & endocrine tumours → tend to have a better prognosis than ductal adenocarcinoma.
• UK incidence: ~7000–8000 new cases annually, poor 5-year survival (<10%).

⚠️ Risk Factors

• 🚬 Smoking (major risk factor).
• 🍺 Alcohol excess, obesity, chronic pancreatitis.
• ☕ High coffee intake (inconclusive evidence).

🧬 Genetic Associations (minority of cases)

• BRCA2 mutation (also ↑ breast/ovarian cancer risk).
• Peutz–Jeghers syndrome, HNPCC (Lynch), FAP.
• CDKN2A mutation (familial atypical multiple mole melanoma).
• Von Hippel–Lindau, MEN syndromes → ↑ risk of pancreatic neuroendocrine tumours.

🔬 Pathology

• Location: 70% head/neck, 20% body, 10% tail.
• Spread: Local invasion (ducts, duodenum, portal vein, lymphatics, nerves) → liver mets common.

🧫 Histology

• Ductal adenocarcinoma (90%) – most common, aggressive.
• Adenosquamous carcinoma (rare).
• Mucinous cystadenocarcinoma (arises from mucinous cystic neoplasm).
• Neuroendocrine tumours (insulinoma, glucagonoma, gastrinoma) – better prognosis.

🩺 Clinical Presentation

• 📉 Weight loss, anorexia (common presenting features).
• 🟡 Painless jaundice with palpable gallbladder = Courvoisier’s sign (suggests malignant obstruction).
• 🤢 Recurrent or unexplained pancreatitis in younger patients.
• 🩸 Trousseau’s syndrome = migratory thrombophlebitis / recurrent DVT/PE.
• 🩺 New-onset diabetes in older patients → red flag for pancreatic cancer.
• ⚡ Epigastric pain radiating to the back, worse lying flat, relieved by leaning forward.

📌 Head vs Body/Tail Tumours

🔎 Investigations

• 🧪 Bloods: FBC (anaemia), U&E, LFTs (cholestatic picture: ↑ALP, ↑bilirubin), clotting, glucose.
• 🎯 Tumour markers: CA19-9 (useful for prognosis/monitoring, not diagnosis).
• 🖥️ Imaging:
  • USS – good for bile duct dilation, but often misses small pancreatic lesions.
  • CT pancreas with contrast = best for diagnosis + staging + operability.
  • ERCP – diagnostic & therapeutic (biliary stenting, brush cytology).
  • EUS-guided biopsy for tissue confirmation.
• 📌 Histology: Mandatory for diagnosis (biopsy or cytology).

⚡ Complications

• Obstructive jaundice + pruritus.
• Duodenal obstruction → vomiting.
• Thrombosis (splenic vein → gastric varices; systemic VTE).
• Severe pain → often needs coeliac plexus block.
• Cholangitis, malignant ascites, secondary diabetes.

💊 Management

• 🎯 Surgical resection (curative in minority):
  • Whipple’s procedure (pancreaticoduodenectomy) for head tumours.
  • Distal pancreatectomy for tail tumours.
• 💉 Neoadjuvant / adjuvant chemotherapy (e.g., FOLFIRINOX, gemcitabine-based).
• 🛠️ Palliation:
  • ERCP with stent (relieve obstructive jaundice).
  • Gastrojejunostomy for duodenal obstruction.
  • Analgesia ± radiotherapy ± coeliac plexus block for pain.
• 🩺 Supportive: Nutritional support, diabetes management, LMWH for VTE prophylaxis.

🌟 Summary: Pancreatic cancer is often advanced at diagnosis. 👉 Think: unexplained weight loss, painless jaundice, new diabetes, recurrent “idiopathic” pancreatitis. 📌 CT pancreas is key for diagnosis & staging. 🚫 USS cannot rule it out. 🩺 Whipple’s is potentially curative, but most require palliation.