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 cancer | 1 |
| Cholangiocarcinoma | 0.11 |
| <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:
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