Summary
Highlights
Pancreatic cancer is often diagnosed late and has a poor prognosis. Most are adenocarcinomas and occur in the head of the pancreas, leading to obstructive jaundice. It tends to spread early, particularly to the liver.
A key presenting feature is painless obstructive jaundice, causing yellow skin and sclera, pale stools, dark urine, and itching. Other vague symptoms include epigastric/back pain, weight loss, a palpable mass, change in bowel habit, nausea, vomiting, or new-onset/worsening diabetes.
Nice guidelines suggest referral for suspected pancreatic cancer: patients over 40 with jaundice require a two-week wait referral. Patients over 60 with weight loss plus other symptoms (diarrhea, back pain, abdominal pain, nausea, vomiting, constipation, or new diabetes) should have a direct access CT of the abdomen.
Courvoisier's Law states a palpable gallbladder with jaundice suggests malignancy, not gallstones. Trousseau's Sign of Malignancy refers to migratory thrombophlebitis, particularly in pancreatic adenocarcinoma.
Diagnosis relies on imaging (CT scan) and histology from a biopsy. A staging CT scan of the thorax, abdomen, and pelvis is done to check for metastases. CA19-9 is a tumor marker, but it's not specific. MRCP is used to assess the biliary system, and ERCP can relieve obstruction and obtain biopsies.
Management is decided at a hepatobiliary multidisciplinary team meeting. Surgery to remove the tumor is considered for small, isolated tumors in the head of the pancreas (about 10% of cases). Surgical options include total pancreatectomy, distal pancreatectomy, pylorus-preserving pancreaticoduodenectomy (modified Whipple's), or radical pancreaticoduodenectomy (Whipple's).
In most cases, curative surgery isn't possible. Palliative treatment includes stents for biliary obstruction, surgery to bypass obstruction, and palliative chemotherapy or radiotherapy to improve symptoms and extend life. End-of-life care focuses on symptom control.
A Whipple's procedure, or pancreaticoduodenectomy, removes a non-spread tumor in the head of the pancreas. It's a major operation involving removal of the head of the pancreas, pylorus of the stomach, duodenum, gallbladder, bile duct, and lymph nodes. A modified Whipple's procedure preserves the pylorus of the stomach.