Pancreatic Cancer

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Pancreatic cancer is a malignant tumour arising from the pancreas, most commonly from the exocrine glands. It is one of the leading causes of cancer-related deaths due to late presentation and rapid progression.

Aetiology

Pancreatic cancer is primarily adenocarcinoma, arising from the exocrine cells of the pancreas. Less common types include neuroendocrine tumours. Causes include:

  • Genetic mutations (e.g., KRAS, CDKN2A).
  • Chronic inflammation (e.g., chronic pancreatitis).
  • Smoking and alcohol use.
  • Familial syndromes (e.g., BRCA mutations, Lynch syndrome).

Pathophysiology

Pancreatic cancer develops through genetic mutations leading to uncontrolled cell proliferation. Most tumours arise in the pancreatic head, causing obstruction of the bile duct, leading to jaundice. Tumour invasion into surrounding tissues and distant metastases commonly occur.

Risk Factors

  • Age (most cases occur in individuals over 60).
  • Smoking (major modifiable risk factor).
  • Obesity and physical inactivity.
  • Chronic pancreatitis.
  • Family history of pancreatic or related cancers.
  • Diabetes mellitus, especially new-onset diabetes in older adults.

Signs and Symptoms

Common Symptoms:

  • Painless jaundice (yellowing of skin and sclera).
  • Dark urine and pale stools (due to bile obstruction).
  • Unintentional weight loss.
  • Epigastric or back pain (worse at night).
  • Loss of appetite and fatigue.

Signs:

  • Palpable mass in the epigastrium (advanced cases).
  • Courvoisier's sign (palpable, non-tender gallbladder in the presence of jaundice).
  • Signs of metastatic disease (e.g., hepatomegaly, ascites).

Investigations

  • Blood tests:
    • Liver function tests (LFTs): elevated bilirubin, ALP, and GGT in biliary obstruction.
    • CA 19-9: a tumour marker often elevated in pancreatic cancer.
    • FBC and coagulation profile: may show anaemia or clotting abnormalities.
  • Imaging:
    • Ultrasound: initial test for obstructive jaundice; may show biliary dilatation or a mass in the pancreas.
    • CT scan (pancreas protocol): gold standard for diagnosis, staging, and operability assessment.
    • MRCP/ERCP: for detailed imaging of the biliary and pancreatic ducts and possible stent placement in obstructive jaundice.
  • Biopsy: endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for histological confirmation.

Management

Management depends on the stage of the disease and fitness of the patient:

1. Surgical Management:

  • Resectable tumours: pancreaticoduodenectomy for tumours in the pancreatic head or distal pancreatectomy for body/tail tumours.

2. Oncological Treatment:

  • Palliative chemotherapy: for advanced disease to improve survival and quality of life.

3. Palliative Care:

  • Biliary stenting: relieves obstructive jaundice.
  • Pain management: opiates for pain relief.
  • Nutritional support: pancreatic enzyme replacement and dietary advice.

Referral

  • Urgent 2ww referral to a specialist (suspected cancer pathway):
    • Painless jaundice or significant weight loss.
    • Suspicious findings on imaging (e.g., pancreatic mass or biliary obstruction).
  • Oncologist referral: for chemotherapy evaluation in resectable and advanced disease.
  • Palliative care team referral: for symptom management and holistic support.
GastroenterologymypanotesPancreatic Cancer