CARCINOMA OF THE PANCREAS

Epidemiology

Pancreatic cancer is the fifth most common cause of cancer death in the Western world. Men are affected more commonly than women, and the incidence increases with age, with most cases occurring in patients over 60 years. Most are adenocarcinomas of ductal origin.

Aetiology

Hereditary (a dominant susceptibility gene in some families and other sus-ceptibility genes in defined syndromes) and environmental factors (smoking and obesity particularly) both contribute. Chronic pancreatitis is also pre-malignant, particularly in patients with hereditary pancreatitis.

Clinical features

Cancer affecting the head of the pancreas or ampulla of Vater presents with painless jaundice as a result of obstruction of the common duct, and weight loss. On examination there is jaundice with characteristic scratch marks and a distended palpable gall bladder (Courvoisier's law: if in a case of painless jaundice the gall bladder is palpable, the cause will not be gallstones). In gallstone disease chronic inflammation and fibrosis prevent distension of the gall bladder. There may be a central abdominal mass.

Cancer of the body or tail presents with abdominal pain, weight loss and anorexia.

Diabetes may occur and there is an increased risk of thrombophlebitis. However, patients may also present with non-specific symptoms, e.g. an elderly patient with dyspepsia and a change in bowel habit.

Investigations

Diagnosis is made by US (which demonstrates dilated bile ducts and a mass lesion) and/or contrast-enhanced spiral CT; the latter is a more sensitive test particularly for body and tail tumours and is almost always necessary to stage the cancer. MRI and endoscopic US is used for staging (endoscopic US) and in difficult cases for diagnosis. ERCP is usually restricted to palliative treat-ment (e.g. bile duct stenting in a jaundiced patient) but may provide a source for cytology in making the diagnosis. The tumour marker, CA19-9 (p. 292), is sensitive but not specific for diagnosis. Serial measurements are more frequently used to monitor response to treatment.

Management

Optimal management is by a multidisciplinary team approach and with advanced disease involvement of the palliative care team particularly to help with management of pain. Surgical resection offers the only hope of cure but few patients have resectable disease at diagnosis. Tumour adherence or invasion into adjacent structures, particularly major blood vessels (locally advanced disease), makes complete resection difficult, and these patients are treated with combined chemotherapy and radiotherapy. 5-Fluorouracil and gemcitabine improve survival in advanced disease and also increase survival as an adjuvant therapy to pancreatic resection. Palliative treatment is often necessary for patients with unresectable pancreatic cancer to relieve obstructive jaundice (usually by endoscopic placement of a stent across the obstructed distal CBD), gastric outflow obstruction, and pain.

Table 4.15 Clinical syndromes resulting from neuroendocrine tumours

Tumour

Secreted hormone

Symptoms

Symptom control

Gastrinoma

(Zollinger-Ellison syndrome)

Gastrin

Duodenal ulceration - recurrent and severe
Diarrhoea- hypersecretion of gastric acid inhibits digestive enzymes

High dose proton pump inhibitors

ViPoma

Vasoactive

intestinal

polypeptide

Severe watery diarrhoea and hypokalaemia due to stimulation of intestinal water and electrolyte secretion

Octreotide

Glucagonoma

Glucagon

Migratory necrolytic dermatitis, weight loss, diabetes mellitus, deep venous thrombosis

Octreotide

Somatostatinoma

Somatostatin

Diabetes mellitus, gallstones, diarrhoea/ steatorrhoea

Octreotide

Overall, the prognosis is very poor. For the few patients who have had surgical resection with curative intent the 3-year survival is 30-40%. The median survival for treated patients with locally advanced disease is 8-12 months and for patients with metastatic disease it is 3-6 months.

Cancer of the Bile Ducts

Like pancreatic cancer, cholangiocarcinoma is also a disease of the elderly with a poor prognosis. It occurs more frequently in patients with primary sclerosing cholangitis, congenital bile duct abnormality and infections with liver flukes e.g. Clonarchis sinensis. Presentation is usually with jaundice secondary to bile duct obstruction or with metastatic disease. Imaging by US, CT or MRI shows a bile duct stricture, a hilar mass or multiple metastases.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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