Pancreatic carcinoma refers to cancerous cells forming in the pancreas. Most often cancer forms in the exocrine pancreas, particularly in the ductal epithelial cells, which case it’s referred to as pancreatic adenocarcinoma.
14th M/C cancer worldwide
7thhighest cause of cancer mortality worldwide
Average survival: 1-2 years
5-year survival rate ~ 6%
Only 20% of patients with pancreatic cancer have surgically resectable disease at time of presentation
After successful resection 27%
Non-modifiable risk factors:
Male (♂ 5.5 : ♀ 4.0)
Age (> 65 years in 90% cases)
African-American race (↑ 50-90% risk)
Non-O blood group
Modifiable risk factors:
Smoking (↑ 74% risk in current smokers & ↑ 20% risk in former smokers): Smoking cessation remains the only recommended measure for the prevention of pancreatic cancer.
High-fat/low-fibre diet + ↑ red-meat
Occupational exposure (industrial/toxic metals)
Alcohol (indirect link: linked to chronic pancreatitis which is linked to pancreatic cancer)
Lynch syndrome (MSH2, MLH1, MSH6, PMS and PMS2 genes)
Familial pancreatic cancer
Cystic fibrosis (CFTR gene)
Breast and ovarian cancer syndrome (BRCA1, BRCA2 and PALB2 genes)
Ataxia telangiectasia (ATM gene)
Li–Fraumeni syndrome (TP53 gene)
Familial pancreatic cancer (7–10% cases have family history):
Families in which a pair of first-degree relatives have been diagnosed with pancreatic tumours (they have an 80% increased risk of developing pancreatic adenocarcinoma compared with individuals with no reported family history)
Pancreatic intraepithelial neoplasia (PanIN) (M/C precursor): Arise from small (<0.5 cm) pancreatic ducts
Intraductal papillary mucinous neoplasm (IPMN): Arise from main pancreatic duct or one of the side branches
Mucinous cyst neoplasms
More than 90% of adenocarcinoma of the pancreas are duct cell adenocarcinomas with other types being cystadenocarcinoma and acinar cell carcinoma. Two-thirds arise in the pancreatic head; one-third arise in the rest (body and tail of pancreas).
Adenocarcinomas (M/C. 75–80%): Characterized by atypical neoplastic glands in a dense stroma
Adenocarcinoma variants (rare): Adenosquamous, hepatoid, medullary, signet ring cell and undifferentiated carcinomas
Neuroendocrine tumours (15–20%): Characterized by a nested growth pattern, ‘salt and pepper’ nuclei and expressing the neuroendocrine markers synaptophysin and chromogranin
Colloid carcinomas (2%): Characterized by formation of pools of mucin in the stroma
Solid-pseudopapillary tumours (2%): Characterized by poorly cohesive cells
Acinar cell carcinomas (1%): Characterized by cells with granular cytoplasm and a single prominent nucleoli
Pancreatoblastomas (0.5%): Characterized by neoplastic cells with acinar differentiation and squamoid nests
Early-stage pancreatic cancer is usually clinically silent, and disease only becomes apparent after the tumour invades surrounding tissues or metastasises to distant organs. Most people who present with symptoms attributable to pancreatic cancer have advanced disease
Painless jaundice (70% cases) (due to obstruction of the common bile duct from the pancreatic head tumor)
Weight loss (90% cases) (arise from anorexia, maldigestion from pancreatic ductal obstruction, and cachexia)
Recurrent deep vein thrombosis (DVT) (due to hypercoagulability, indicative of malignant disease)
The majority of cases present late, with either locally advanced or metastatic disease
Non-specific, as similar in smokers.
↑ Serum amylase
↑ Serum lipase
↑ CA 19-9 Antigen (immune surveillance)
↑ CEA (glycoprotein involved in cell adhesion)
↑ Alkaline phosphatase (ALP)
Frostberg reverse/inverted 3 sign: Broadening of the duodenal loop with a ‘puckering’ around the ampulla of Vater, classically associated with pancreatic adenocarcinoma at the head of the pancreas
Multidetector CT (MDCT):
Best imaging modality to diagnose and evaluate the extent of disease including perivascular extension and distant metastasis. Not preferred as multiple imaging studies required during treatment which will expose patient to unnecessary amounts of radiation
Preoperative evaluation of pancreatic cancer and the assessment of vascular invasion.
Double duct sign
ERCP + EUS ± biopsy:
Level of biliary or pancreatic obstruction can be delineated. In some case, placement of a biliary stent can help relieve symptoms of jaundice.
Endoscopic retrograde cholangiopancreatography (ERCP): Contrast dye is injected into the biliary ducts and pancreatic duct with an endoscope
Endoscopic ultrasound (EUS): Delineate the pancreatic mass and can be used to biopsy the mass under ultrasound guidance.
Fine needle aspiration biopsies can be done of suspicious lesions for the pathologic specimen
Fine needle aspiration biopsy:
Peptic ulcer disease
Close proximity to major blood vessels results in readily invadsion by tumour. This means that 80%-85% of tumours are not resectable at the time of presentation.
Only potential cure for pancreatic cancer, although rates of recurrence are high with inevitably dismal rates of long-term survival. Treatment depends on location of the primary tumour: the pancreatic head, neck or uncinate process (70%); the body or tail (20%); or multifocal disease (10%)
Pancreatico-duodenectomy (Whipple’s procedure): Lesions of head, neck and uncinate process
Distal pancreatectomy: Lesions of the body or tail