Introduction

Pancreatic cancer is often diagnosed late as it tends to present in a non-specific way.

Epidemiology

  • Incidence: 15.00 cases per 100,000 person-years
  • Peak incidence: 70+ years
  • Sex ratio: 1:1
Condition Relative
incidence
Pancreatic cancer1
Cholangiocarcinoma0.11
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

Associations
  • increasing age
  • smoking
  • diabetes
  • chronic pancreatitis (alcohol does not appear an independent risk factor though)
  • hereditary non-polyposis colorectal carcinoma
  • multiple endocrine neoplasia
  • BRCA2 gene

Pathophysiology

Over 80% of pancreatic tumours are adenocarcinomas which typically occur at the head of the pancreas.

Clinical features

Features
  • classically painless jaundice
  • Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (
  • however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
  • loss of exocrine function (e.g. steatorrhoea)
  • loss of endocrine function (e.g. diabetes mellitus)
  • atypical back pain is often seen
  • migratory thrombophlebitis (Trousseau sign) is more common than with other cancers

Referral criteria

NICE cancer referral guidelines for pancreatic cancer suggest the following:


Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice.

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:
  • diarrhoea
  • back pain
  • abdominal pain
  • nausea
  • vomiting
  • constipation
  • new‑onset diabetes

Investigations

Investigation
  • ultrasound has a sensitivity of around 60-90%
  • high-resolution CT scanning is the investigation of choice if the diagnosis is suspected

Management

Management
  • less than 20% are suitable for surgery at diagnosis
  • a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease
  • adjuvant chemotherapy is usually given following surgery
  • ERCP with stenting is often used for palliation