Key facts

≈3% of all malignancy; ~9000 deaths/yr (UK)
Typically male patient in their 70s
Major risk factors: smoking, chronic pancreatitis, diabetes mellitus, ↑waist circumference (ie adiposity), Red or processed meat diet
Metastasize early; present late
Extremely poor prognosis

Pathology

Mostly (90%) ductal adenocarcinoma
60% arise in the pancreas head, 25% in the body, 15% tail
Other site of origin (better prognosis): Ampulla of Vater (ampullary tumour), pancreatic islet cells (insulinoma, gastrinoma, glucagonomas, somatostatinomas, VIPomas)
~95% have mutations in the KRAS2 gene

Tumours in the head of the pancreas present with painless obstructive jaundice
Tumours in the body and tail present with epigastric pain (radiates to back and relieved by sitting forward)
Anorexia, weight loss, diabetes, or acute pancreatitis.
Rarer features:
- Thrombophlebitis migrans (eg an arm vein becomes swollen and red, then a leg vein); ↑Calcium
- Marantic endocarditis
- Portal hypertension (splenic vein thrombosis)
- Nephrosis (renal vein metastases)

Jaundice + palpable gallbladder (Courvoisier’s ‘law’) → cancer until proven otherwise
Epigastric mass
Hepatomegaly/ splenomegaly
Lymphadenopathy
Ascites

Blood: Cholestatic jaundice,↑Ca19–9
Imaging:
- US or CT (pancreatic mass ± dilated biliary tree ± hepatic metastases, help guide biopsy, stent insertion)
- ERCP/MRCP for bile duct assessment
- EUS (endoscopic ultrasonography)

Most ductal cancers present with metastatic disease; <20% are suitable for radical surgery.

Surgery: pancreatoduodenectomy (Whipple’s procedure) when no distant metastases and where vascular invasion is still at a minimum.
Laparoscopic excision if tail lesion
Adjuvant chemotherapy- delays disease progression
Endoscopic or percutaneous stent insertion for jaundice palliation
Pain- ↑ dose opiates, coeliac plexus infiltration with alcohol