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Pancreatic carcinoma

Epidemiology

  • More common in men
  • Peak incidence is >65 years old
  • African-American people are affected more
  • Poor prognosis at time of presentation – usually local and distant metastasis
    • Mean survival time for adenocarcinoma is 9-12 months

Etiology

  • Cigarette smoking
  • Processed meats – containing N-nitroso compounds
  • Diabetes mellitus, chronic pancreatitis
  • Alcohol, caffeine
  • Peutz-Jeghers syndrome
  •   HNPCC

    • Pathophysiology

    • Carcinoma arises from the exocrine portion of the pancreas
      • Most commonly from pancreatic acinar cells and ductal epithelium
    • Alcohol etiology is most common in carcinoma of head of pancreas

    Metastasis

    • From the body and tail of pancreas it metastasises to parapancreatic and splenic lymph nodes
    • From the head of pancreas it metastasises to the hepatoduodenal ligament
    • Local spread – to adjacent structures i.e. duodenum, portal vein, superior mesenteric vein
    • Distant spread – liver, lungs, adrenals, brain, bone

    Clinical features

    • Initially, vague symptoms – anorexia, weight loss, abdominal discomfort, pain after eating
    • First significant symptom – mechanical jaundice
      • Occurs when tumour infiltrates the cystic duct
    • Pain in upper abdomen and back
    • Troisier’s sign – palpable Virchhow’s node
      • Due to thoracic duct obstruction
      • Also seen in cancer of the lungs, oesophagus, stomach
    • Courvoisier sign – a palpable, non-tender gallbladder in the presence of mild jaundice suggests malignancy
    • Trousseau’s sign – migratory superficial thrombophlebitis
    • Sister Mary Joseph nodule – palpable nodule bulging into umbilicus as a result of metastases in pelvis/abdomen
    • Intestinal obstruction – tumour in head of pancreas compresses duodenum

    Investigations

    • CT with contrast
    • MRI – for metastases
    • Cholangiography – to look for infiltration of major pancreatic duct
    • CEA tumour marker – useful for follow-up (if CEA levels don’t decrease after resection, it signifies an unsuccessful resection)

    Treatment

    • Whipple’s operation (see pic) – pancreaticoduodenectomy
      • 3 anastomoses – pancreaticojejunostomy, choledojejunostomy, gastrojejunostomy

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