Pancreatic Cancer

Cheatsheet Content

### Pancreatic Cancer: Overview - **Definition:** Malignant neoplasm arising from the exocrine or endocrine cells of the pancreas. - **Prevalence:** Relatively rare but highly aggressive. - **Prognosis:** Poor, often diagnosed at advanced stages. 5-year survival rate ~11%. - **Risk Factors:** - Smoking (2x increased risk) - Chronic pancreatitis - Diabetes (Type 2, long-standing) - Obesity - Family history/Genetic syndromes (e.g., BRCA2, Lynch syndrome) - Age (median age at diagnosis: 70 years) ### Pathology & Types - **Exocrine Tumors (95%):** - **Pancreatic Ductal Adenocarcinoma (PDAC):** Most common type, arising from ductal epithelial cells. - Acinar Cell Carcinoma, Intraductal Papillary Mucinous Neoplasm (IPMN) with invasive carcinoma, Mucinous Cystic Neoplasm (MCN) with invasive carcinoma. - **Endocrine Tumors (Pancreatic Neuroendocrine Tumors - PNETs, ### Clinical Presentation - **Early Stage:** Often asymptomatic or non-specific symptoms. - **Late Stage/Common Symptoms:** - **Jaundice:** Painless, obstructive jaundice (due to common bile duct compression in head tumors). Dark urine, pale stools, pruritus. - **Abdominal Pain:** Vague, dull, epigastric pain radiating to the back (classic for body/tail tumors). Worsens with eating or lying down. - **Weight Loss & Anorexia:** Unexplained, significant weight loss. - **New-onset Diabetes:** Sudden development or worsening of diabetes. - **Steatorrhea:** Fatty stools due to pancreatic enzyme insufficiency. - **Nausea/Vomiting:** Gastric outlet obstruction. - **Courvoisier's Sign:** Painless, palpable gallbladder (indicates extrahepatic biliary obstruction, often malignant). - **Trousseau's Syndrome:** Migratory thrombophlebitis. ### Diagnosis - **Laboratory Tests:** - **Tumor Markers:** CA 19-9 (Carbohydrate Antigen 19-9) – not diagnostic, but useful for monitoring treatment response and recurrence. Elevated in ~80% of PDAC, but also in other conditions (cholangitis, pancreatitis). - Liver function tests (LFTs): Elevated bilirubin, alkaline phosphatase (ALP) in obstructive jaundice. - Amylase/Lipase (usually normal unless pancreatitis is present). - **Imaging:** - **CT Scan (Multi-detector computed tomography - MDCT):** Preferred initial imaging. Triple-phase CT for pancreatic protocol provides detailed information on tumor resectability (vascular involvement). - **MRI/MRCP:** Useful for evaluating biliary tree obstruction, small lesions, and cystic lesions. - **Endoscopic Ultrasound (EUS):** Highly sensitive for small lesions, allows for fine-needle aspiration (FNA) biopsy for definitive diagnosis. - **PET Scan:** For staging, detecting metastases. - **Biopsy:** - **EUS-guided FNA:** Most common and safest method for tissue diagnosis. - Percutaneous biopsy: Less common due to risk of tumor seeding. - Surgical biopsy: If other methods are inconclusive. ### Staging (AJCC TNM Classification) - **T (Tumor):** Size and extent of primary tumor. - **N (Nodes):** Regional lymph node involvement. - **M (Metastasis):** Distant metastasis (liver, peritoneum, lung most common). - **Stages:** - **Stage 0:** Carcinoma in situ. - **Stage I-II:** Localized, potentially resectable. - **Stage III:** Locally advanced, unresectable due to vascular involvement. - **Stage IV:** Metastatic disease, unresectable. - **Resectability Classification:** - **Resectable:** No arterial or venous involvement, clear fat planes. - **Borderline Resectable:** Some venous involvement (e.g., short segment SMV/PV occlusion), or minimal arterial abutment. May become resectable after neoadjuvant therapy. - **Locally Advanced Unresectable:** Extensive arterial involvement (SMA, Celiac), or extensive venous involvement (SMV/PV occlusion not amenable to reconstruction). - **Metastatic Unresectable:** Distant spread. ### Treatment - **Surgical Resection (Curative Intent):** Only option for cure, but only ~15-20% of patients are eligible. - **Pancreaticoduodenectomy (Whipple Procedure):** For tumors in the head of the pancreas. Removes pancreatic head, duodenum, gallbladder, part of common bile duct. - **Distal Pancreatectomy & Splenectomy:** For tumors in the body or tail. - **Total Pancreatectomy:** Rarely, for extensive disease. - **Adjuvant Therapy:** Chemotherapy (e.g., Gemcitabine, FOLFIRINOX) after surgery to reduce recurrence. - **Neoadjuvant Therapy:** Chemotherapy and/or radiation BEFORE surgery for borderline resectable or some resectable tumors to downstage and improve surgical outcomes. - **Palliative Treatment (for unresectable/metastatic disease):** - **Chemotherapy:** To prolong survival and improve quality of life (e.g., FOLFIRINOX, Gemcitabine + Abraxane). - **Radiation Therapy:** For pain control, local tumor control. - **Biliary Stenting:** For obstructive jaundice (endoscopic or percutaneous). - **Gastric Bypass:** For gastric outlet obstruction. - **Pain Management:** Opioids, celiac plexus block. - **Pancreatic Enzyme Replacement Therapy (PERT):** For exocrine insufficiency. - **Nutritional Support:** Dietetics, feeding tubes. ### Prognosis & Follow-up - **Prognosis:** Generally poor due to late diagnosis and aggressive nature. Median survival for metastatic disease is