Definitions
Pancreatic adenocarcinoma is a malignant lesion of the head, body or tail of the pancreas. Periampullary carcinomas arise around the ampulla of Vater and include tumours arising from the pancreas, duodenum, distal bile duct and the ampulla itself. Neuroendocrine tumours of the pancreas cause a variety of syndromes secondary to the secretion of active peptides.
Key Points
- Most pancreatic cancer is not surgically curable. Overall 5-year survival is only 5%.
- New, chronic back pain and vague symptoms may be the only presenting feature.
- The best prognosis is for true periampullary cancers.
- Good palliation of jaundice is possible without surgery.
Epidemiology
Male : female 2:1, peak incidence 50–70 years. Incidence of pancreatic carcinoma is increasing in the Western world.
Aetiology
Predisposing factors: smoking, diabetes, chronic pancreatitis.
Pathology
- Site: 55% involve head of pancreas, 25% body, 15% tail, 5% periampullary region.
- Macroscopic: growth is hard and infiltrating.
- Histology: 90% ductal carcinoma, 7% acinar cell carcinoma, 2% cystic carcinoma, 1% connective tissue origins.
- Spread:
local into vital structures (portal vein, superior mesenteric vessels)
lymphatics to peritoneum and regional nodes
via bloodstream to liver and lung – metastases often present at time of diagnosis.
Clinical Features
- Jaundice, abdominal pain and weight loss, 50% have one of these symptoms.
- Head or periampullary: painless, progressive jaundice with a palpable gallbladder (Courvoisier’s law: a palpable gallbladder in the presence of jaundice is unlikely to be due to gallstones).
- Occasionally, duodenal obstruction causing vomiting.
- Body: back pain, anorexia, weight loss, steatorrhoea.
- Tail: often presents with metastases, malignant ascites or unexplained anaemia.
- New onset diabetes may be first presentation in up to 10% of patients
Investigations
- Ultrasound: may see mass in head of pancreas and distended biliary tree.
- Spiral CT scan: demonstrates tumour mass, facilitates biopsy, assess involvement of surrounding structures and local lymph node spread. Best method for staging.
- EUS ± fine needle biopsy: staging, vascular involvement, tissue diagnosis.
- MRCP/ERCP: very accurate in making diagnosis; obtain specimen or shed cells for cytology and stent may be placed to relieve jaundice.
- (Barium meal: widening of the duodenal loop with medial filling defect, the reversed ‘3’ sign. Not used very much anymore.)
- Tumour marker (CA19.9) not diagnostic but useful to monitor treatment response.
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