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Chapter: Medicine and surgery: Hepatic, biliary and pancreatic systems

Carcinoma of the pancreas - Tumours of the pancreas

Malignant tumours of the exocrine pancreas.

Tumours of the pancreas


Carcinoma of the pancreas




Malignant tumours of the exocrine pancreas.




10 per 100,000 per annum and rising.




Mainly >60 years.



2M : 1F




In many Western countries it is the fourth commonest cause of cancer death in males and in females, the sixth.




There appears to be some familial clustering and hence it is suggested that genetic susceptibility may play an important role. Specific inherited risks include familial pancreatitis and familial cancer syndromes such as Peutz–Jegher syndrome and Von Hippel Lindau syndrome. Smoking is the only environmental factor firmly associated although high-fat diets and exposure to chemical carcinogens are thought to be contributory.




The majority of carcinomas of the pancreas are ductal adenocarcinomas. Acinar cell carcinomas, cystadenocarcinomas and sarcomas are all rare. Most tumours develop in the head of the pancreas and these tend to present early with obstructive jaundice.


Clinical features


Pancreatic cancer is associated with several clinical syndromes:


·        One third of patients present with painless obstructive jaundice, i.e. dark urine and pale stool, with palpable dilatation of the gallbladder (Courvoisier’s sign).


·        Weight loss, anorexia are common. Chronic epigastric pain radiating to the back similar to chronic pancreatitis develops in most patients at some stage.


·        Migratory thrombophlebitis and deep vein thrombosis of the legs (Trousseau’s syndrome).


·        Pancreatic insufficiency: One third of patients have impaired glucose tolerance or diabetes mellitus. Steatorrhoea is common and failure to absorb the fat-soluble vitamin K may cause coagulopathy.




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 pancreas. Most tumours are moderately differentiated adenocarcinoma with a prominent fibrous stroma.



The main routes of spread are local causing obstructive jaundice or invasion of the duodenum, lymphatic to adjacent lymph nodes which drain into the coeliac and superior mesenteric lymph nodes and haematogenous mainly to the liver. Seventy-five per cent of patients have metastases at the time of presentation.




There are no useful tumour markers or pancreatic function tests for diagnosis, which must be histological.


·        Ultrasound scan shows a dilated biliary tree, excludes gallstones and may show the mass lesion in the pancreas or metastases in the liver. Endoscopic ultrasound is increasingly used.


·        CT scanning has sensitivity of greater than 95% for the detection of pancreatic tumours.


·        Percutaneous fineneedle aspiration or Trucut needle biopsy under ultasound or CT guidance can be carried out.


·        ERCP allows assessment of both pancreatic and biliary ducts and may also be used for intervention. Biopsies along with aspiration of pancreatic juice and bile can be sampled for cytology.




Surgical resection offers the only chance of cure, but only about 10–15% of patients are suitable for radical surgery depending on tumour size, invasion of blood vessels and the presence of ascites or metastases.


·        Whipple’s procedure is a radical pancreaticoduo-denectomy with block resection of the head of pancreas, distal half of the stomach, duodenum, gallbladder and common bile duct. Reconstruction involves anastomoses of the jejunum and the pancreatic remnant, the common hepatic duct and gastric remnant are anastomosed to the jejunum. There is significant perioperative morbidity and mortality.


·        Palliative treatment aims are to relieve jaundice, pruritus, pain and duodenal obstruction. Stents of the bile duct and/or duodenum tend to become blocked and have to be replaced.




The prognosis is extremely poor with an overall 5-year survival of <5% (most in the first 6 months). The 5-year survival of patients who undergo curative resection is 30%.

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