Pancreatic Cancer
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Direct answer
Pancreatic cancer is usually a ductal adenocarcinoma of the head of the pancreas, presenting late with painless obstructive jaundice, weight loss or new-onset diabetes. Smoking is the strongest modifiable risk factor, and chronic pancreatitis and inherited BRCA2 or PALB2 variants add to the risk. Only a minority are resectable at diagnosis, so pancreas-protocol CT staging and biliary drainage decide the plan, and most patients need palliation of obstruction.
What you must remember
- Commonest type: ductal adenocarcinoma, about two-thirds arising in the head, where jaundice appears early because the distal bile duct is compressed.
- Risk factors: smoking, chronic pancreatitis, new-onset diabetes after age 50, obesity, a family history and germline BRCA2 or PALB2 variants.
- CA 19-9: used for monitoring treatment and detecting recurrence; it is raised by biliary obstruction and absent in Lewis-negative people, so it cannot screen.
- Courvoisier sign: a painless, palpable, distended gallbladder with jaundice suggests malignant obstruction of the distal common bile duct rather than gallstones.
- Trousseau sign: migratory superficial thrombophlebitis is a paraneoplastic clue that may precede the diagnosis by months.
- Whipple resection: pancreaticoduodenectomy is the only curative option for resectable head tumours, followed by adjuvant chemotherapy.
- Palliation: metal biliary stents, duodenal stents or gastrojejunostomy for gastric outlet obstruction, and coeliac plexus block for pain.
A jaundiced patient walked through the work-up
Consider a 62-year-old man with three weeks of painless jaundice, pale stools, a 6 kg weight loss and a newly raised blood sugar. Ultrasound shows a dilated intrahepatic biliary tree and a mass at the pancreatic head.
- Image for resectability: A pancreas-protocol triphasic CT asks whether the tumour encases the superior mesenteric artery or narrows the superior mesenteric or portal vein.
- Decompress the bile duct if needed: After CT, an endoscopic stent is placed for cholangitis, delayed surgery or neoadjuvant therapy; obstruction itself raises CA 19-9 and makes the marker unreliable for monitoring.
- Confirm tissue: Endoscopic ultrasound with fine-needle aspiration gives tissue confirmation, which matters before neoadjuvant therapy.
- Resect if clear: If the vessels are clear and there is no distant disease, the patient goes to pancreaticoduodenectomy followed by adjuvant chemotherapy.
- Manage encasement: Arterial encasement makes the tumour unresectable and usually leads to neoadjuvant chemotherapy in selected centres.
- Treat metastatic disease: Chemotherapy such as FOLFIRINOX or gemcitabine with nab-paclitaxel is given if he is fit, alongside pancreatic enzyme replacement, glycaemic control and pain relief.
Where the examiner tests the pattern
Four traps recur in pancreatic cancer questions.
- Trap: treating head tumours and body or tail tumours as the same. Correct: head tumours cause painless obstructive jaundice early, whereas body and tail tumours present late with back pain, weight loss and new diabetes.
- Trap: using CA 19-9 as a diagnostic test in a jaundiced patient. Correct: the marker also rises in cholestasis and cholangitis, so it is never used alone for diagnosis.
- Trap: assuming a palpable gallbladder means gallstones. Correct: the Courvoisier principle holds that a palpable non-tender gallbladder with jaundice is unlikely to be caused by stones, because gallstone disease usually leaves a shrunken, fibrosed gallbladder.
- Trap: calling new diabetes type 2 without imaging. Correct: a new diabetic over 50 with unexplained weight loss deserves pancreatic imaging before the diabetes is labelled type 2.
Frequently asked questions
Why is CA 19-9 unsuitable as a screening test for pancreatic cancer?
CA 19-9 is unsuitable for screening because it is raised by benign biliary obstruction, cholangitis and chronic pancreatitis, so its positive predictive value in asymptomatic people is low. People who lack the Lewis antigen cannot produce it at all, a small minority of the population. Its main value is in monitoring treatment response and detecting recurrence.
What is the Courvoisier sign and what does it indicate?
The Courvoisier sign is a palpable, non-tender, distended gallbladder in a jaundiced patient, and it suggests malignant obstruction of the distal common bile duct, most often from pancreatic head cancer. Its presence argues against gallstones as the cause of jaundice, since gallstone disease usually leaves a small, fibrosed gallbladder.
Which operation is curative for carcinoma of the head of the pancreas?
Pancreaticoduodenectomy, the Whipple procedure, is the only curative operation for carcinoma of the head of the pancreas, and it is offered only when staging shows the tumour is resectable. Adjuvant chemotherapy follows surgery, and the operation is best performed in high-volume centres where complication rates are lower.
Which procedure relieves obstructive jaundice in unresectable pancreatic cancer?
Endoscopic biliary stenting, preferably with a self-expanding metal stent, relieves obstructive jaundice in unresectable pancreatic cancer and is usually chosen over a plastic stent because it stays patent for longer.
Which chemotherapy regimens are used for metastatic pancreatic adenocarcinoma?
In fit patients with metastatic pancreatic adenocarcinoma, FOLFIRINOX and gemcitabine combined with nab-paclitaxel are the standard first-line options, with the choice guided by performance status and comorbidity. Gemcitabine alone or fluoropyrimidine-based regimens remain options for patients who are less fit.