Pancreatic carcinoma

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Pancreatic cancer is the fourth leading cause of cancer death in males, and the fifth in females, with a slight male predominance of (1.7:1). Usually, patients are elderly. The major risks are cigarette smoking (1.5x the risk for heavy smokers), meat consumption, high fat diets, exposure to industrial solvents, and hereditary pancreatitis (30% will develop carcinoma).

Adenocarcinomas are the majority (85-90%) and arise from the duct system. Most other tumours are rare, but may enter into the differential diagnosis of a pancreatic mass. They include lymphomas, endocrine tumors, sacomas and so on. Most of these tumours (60%) occur in the head of the pancreas, 13% in the body and 5% in the tail. In 21% of cases, the tumour is multifocal. Tumours of the head may obstruct the ampulla of Vater or the common bile duct, making jaundice a common presentation. Grossly, the tumour is a yellow-gray, firm, ill-defined mass.

Patients with adenocarcinoma usually present with weight loss (90%), pain (75%) in upper abdomen and possibly back, obstructive jaundice (65%), anorexia (60%), and diabetes (15%).

Management

In cases of adenocarcinoma, lymphoma and endocrine tumors are uncommon but very treatable. As such, tissue should always be tested in younger patients. Only 10-20% of patients with adenocarcinoma are judged to be resectable at the time of diagnosis, and as such treatment is usually palliative (3.5% 5-year survival). With unresectable tumours, mean survival time is 3 months. When surgical intervention is pursued, Whipple's pancreaticoduodenotomy is the operation of choice. There is no clear evidence of a survival benefit for radiation or chemotherapy.

Stage A:

  • confined to the pancreas alone
  • 13 month survival
  • 5 year survival with curative resection of pancreatic head (7-10%)

Stage B:

  • involving neighboring structures
  • 7 month survival

Stage C:

Stage D:

  • involving liver or other distant spread
  • 2 month survival