Pancreatic cancer, PC

Notes
  • PC is generally fatal as it is often diagnosed late. Its 5-yr survival is less than 2%.
  • Majority of cases of PC are due to adenocarcinomas from duct cells at the head of the gland.
  • The risk factors for PC are: alcohol, tobacco, obesity, processed food, pancreatitis, diabetes and genetic predisposition
  • Statistics: the most common age that is affected by PC - ≥65; annual incidence in globally - 338,000 cases; annual incidence in USA - 46,400 cases (with 39,600 deaths); proportion of PC that may not be surgically unresectable globally at time of diagnosis - 80 to 90%; proportion of PC that is due to hereditary conditions (such as hereditary pancreatitis, Peutz–Jeghers syndrome, familial malignant melanoma, hereditary breast and ovarian cancer syndrome and Lynch syndrome) – 5 to10%.
Symptoms
  • Asymptomatic in early stage in most cases.
  • Abdominal pain (often severe)
  • Back pain
  • Diabetes (very common, especially with tail and body PC)
  • Gastric and esophageal varices
  • Gastrointestinal hemorrhage
  • Jaundice
  • Pruritus (due to jaundice)
  • Pancreatic exocrine insufficiency (reduced production of digestive enzymes)
  • Splenomegaly (due to the obstruction of splenic vein)
  • Weight loss
Diagnosis
  • A contrast enhanced computerized tomography (CT) scan is the test of choice.
  • Magnetic resonance cholangiopancreatography (MRCP).
  • Abdominal ultrasound (especially for initial evaluation of biliary system).
  • Ultrasound-guided fine-needle aspiration or endoscopic ultrasound-guided fine-needle aspiration and histology.
  • Laparotomy and laparascopy (open biopsies) to be used only when other methods cannot be used.
  • CA 19-9 antigen test to monitor progress (rising levels signify poor prognosis)
Differential
  • Acute Pancreatitis
  • Abdominal aortic aneurysm
  • Ampullary carcinoma
  • Cholangitis
  • Cholecystitis
  • Choledochal Cysts
  • Cholelithiasis
  • Chronic Pancreatitis
  • Gastric Cancer
  • Hepatoma
  • Peptic Ulcer Disease
Prevention
  • An estimated 19% of PC can be prevented by weight management.
Management
  • Surgery- mainly “Whipple” procedure (pancreaticoduodenectomy)

_Only applicable in PC that has not metastasized.

_The head of the pancreas, the gallbladder, part of the duodenum, the pylorus, and the lymph nodes near the head of the pancreas are removed. The body and tail of pancreas, the bile, the stomach and the intestines are reconnected.

  • Adjuvant therapy include the following: mainly 5-fluorouracil (5-FU) though other drugs such as gemcitabine, irinotecan, paclitaxel, oxaliplatin and carboplatin may be used and;
  • External beam radiation therapy
  • In case of metastasis or any other cases of unresectable PC, palliative surgery may be recommended and may include;

_Double gastric bypass operation

_Biliary bypass operation

_Pancreatic enzyme supplements

_Appropriate analgesics

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