Pancreatic carcinoma

• 2% of all malignancies
• Generally in males >60
• Risk factors – smoking, alcohol, diabetes, chronic pancreatitis
• 95% have mutations in the KRAS2 gene
• Mostly ductal adenocarcinomas – 60% in head, 25% in body, 15% in tail
• A few arise in the Ampulla of vater or pancreatic islet cells and have better prognosis

Symptoms and signs

• Tumours in the head of the pancreas present with painless jaundice
• 75% of tumours in the body and the tail present with epigastric pain which radiates to the back and is relieved by sitting forward
• Either may cause anorexia, diabetes, acute pancreatitis
• Rarer features;
  • Thrombophebitis migrans – arm vein becomes swollen and red and then a leg vein
  • Raised calcium
  • Marantic endocarditis
  • Portal hypertension (splenic vein thrombosis)
  • Nephrosis (renal vein thrombosis)

Other signs

• Jaundice plus palpable gallbladder
• Epigastric mass
• Hepatomegaly
• Splenomegaly
• Lymphadenopathy
• Ascites

Test

• Bloods – cholestatic picture plus raised Ca19-9
• US/CT

Treatment

• Less than 10% are suitable for radical surgery
• Do a pancreatoduodenectomy (Whipple’s) if fit, tumour <3cm and no mets
• Post op chemo may delay disease progession
• Consider palliation of jaundice
• Pain relief – may require large doses of opiates – can infiltrate the coeliac axis with alcohol at the time of surgery or later percutaenously

Prognosis

• Poor – <6mth mean, 5 year survival <2%