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Tumours of the pancreas 

Tumours of the pancreas

Chapter:
Tumours of the pancreas
Author(s):

Edward Britton

and Martin Lombard

DOI:
10.1093/med/9780199204854.003.152403_update_001

Update:

Pathology—expanded discussion of cystic neoplasms of the pancreas and pancreatic intra epithelial neoplasia.

Clinical investigation—use of endoscopic ultrasound fine needle aspiration or biopsy (EUS-FNAB) and of molecular tumour markers.

Treatment—use of adjuvant chemotherapy with gemcitabine; use of combination chemotherapy; discussion of self expanding metal stents (SEMS).

Updated on 28 Nov 2012. The previous version of this content can be found here.
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date: 24 March 2017

Pancreatic cancer, most commonly in the form of a solid ductal adenocarcinoma, accounts for 3% of all cancers but ranks in the top five leading causes of cancer deaths in most developed countries, reflecting the fact that it has a very poor prognosis (median survival 6 to 9 months). It is a disease of old age (85% of patients >65 years), and commoner in smokers.

Most patients present with locally advanced or metastatic disease, often with obstructive jaundice. Pain is unusual in early disease, but when present is characteristically described as ‘gnawing’, ever present, and frequently radiating into the back. Weight loss is commonly due to anorexia as a result of jaundice or pain, but can occasionally be the only presenting symptom. Increased use of abdominal imaging means that incidental discovery of pancreatic cancer is becoming more common.

Serum biochemistry will typically show elevated bilirubin and a cholestatic picture of liver enzymes, with particular elevation of alkaline phosphatase and γ‎-glutamyl transferase. Transabdominal ultrasonography is usually the primary investigation in a patient with jaundice and can detect pancreatic tumours >2 cm in size or hepatic metastases with a diagnostic accuracy of 75%, but identifies smaller tumours much less reliably. The essential investigations for the diagnosis and staging of pancreatic cancer are contrast-phased CT scan and occasionally MRI.

The only curative treatment for pancreatic cancer is surgical excision. This is technically feasible in up to 40% patients at presentation, but even after careful selection almost 40% of these will have positive microsopic resection margins, and overall postoperative survival is only around 10% at 5 years, the remainder experiencing metastatic disease in the peritoneum, liver, or lungs. Adjuvant chemotherapy with gemcitabine can double the 5-year survival rate.

Palliative management may require biliary stenting for jaundice, duodenal stenting (or surgical bypass) for gastric outlet obstruction, and pain control.

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