Page 225 - Medicine and Surgery

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Chapter 5: Disorders of the pancreas 221

Sex Complications
2M : 1F The main routes of spread are local causing obstruc-
tive jaundice or invasion of the duodenum, lymphatic to
Geography adjacent lymph nodes which drain into the coeliac and
In many Western countries it is the fourth commonest superior mesenteric lymph nodes and haematogenous
cause of cancer death in males and in females, the sixth. mainly to the liver. Seventy-five per cent of patients have
metastases at the time of presentation.

Aetiology
There appears to be some familial clustering and hence Investigations
it is suggested that genetic susceptibility may play an There are no useful tumour markers or pancreatic func-
important role. Specific inherited risks include famil- tion tests for diagnosis, which must be histological.
ial pancreatitis and familial cancer syndromes such as Ultrasound scan shows a dilated biliary tree, excludes
Peutz–Jegher syndrome and Von Hippel Lindau syn- gallstones and may show the mass lesion in the pan-
drome. Smoking is the only environmental factor firmly creasormetastasesintheliver.Endoscopicultrasound
associatedalthoughhigh-fatdietsandexposuretochem- is increasingly used.
ical carcinogens are thought to be contributory. CT scanning has sensitivity of greater than 95% for
the detection of pancreatic tumours.
Percutaneousfine-needleaspirationorTru-cutneedle
Pathophysiology
The majority of carcinomas of the pancreas are ductal biopsy under ultasound or CT guidance can be carried
adenocarcinomas.Acinarcellcarcinomas,cystadenocar- out.
cinomasandsarcomasareallrare.Mosttumoursdevelop ERCPallowsassessmentofbothpancreaticandbiliary
intheheadofthepancreasandthesetendtopresentearly ducts and may also be used for intervention. Biopsies
with obstructive jaundice. along with aspiration of pancreatic juice and bile can
be sampled for cytology.

Clinical features
Pancreatic cancer is associated with several clinical syn- Management
dromes: Surgical resection offers the only chance of cure, but only
One third of patients present with painless obstructive
about 10–15% of patients are suitable for radical surgery
jaundice, i.e. dark urine and pale stool, with palpable depending on tumour size, invasion of blood vessels and
dilatation of the gallbladder (Courvoisier’s sign). the presence of ascites or metastases.
Weight loss, anorexia are common. Chronic epigastric
Whipple’s procedure is a radical pancreaticoduo-
pain radiating to the back similar to chronic pancre- denectomy with block resection of the head of pan-
atitis develops in most patients at some stage. creas, distal half of the stomach, duodenum, gallblad-
Migratory thrombophlebitis and deep vein thrombo-
der and common bile duct. Reconstruction involves
sis of the legs (Trousseau’s syndrome). anastomoses of the jejunum and the pancreatic rem-
Pancreatic insufficiency: One third of patients have
nant, the common hepatic duct and gastric remnant
impaired glucose tolerance or diabetes mellitus. Steat- are anastomosed to the jejunum. There is significant
orrhoea is common and failure to absorb the fat- perioperative morbidity and mortality.
soluble vitamin K may cause coagulopathy. Palliativetreatmentaimsaretorelievejaundice,pruri-
tus, pain and duodenal obstruction. Stents of the bile
duct and/or duodenum tend to become blocked and
Macroscopy/microscopy
have to be replaced.
The tumour is hard yellow-white in appearance. 60% of
tumours arise in the head of the pancreas, 10% in the
body, 10% in the tail and 20% diffusely involve the whole Prognosis
pancreas. Most tumours are moderately differentiated The prognosis is extremely poor with an overall 5-year
adenocarcinoma with a prominent fibrous stroma. survival of <5% (most in the first 6 months). The 5-year