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Pancreatic ductal carcinoma

Dr Yuranga Weerakkody and Dr Frank Gaillard et al.

Pancreatic ductal carcinoma makes up the vast majority (90% ⁵) of all pancreatic neoplasms, and remains a disease with very poor prognosis and high morbidity.

Demographics and clinical presentation

Pancreatic cancer accounts for 22% of all deaths due to gastrointestinal malignancy, and 5% of all cancer deaths ¹. In general it is a malignancy of the elderly with over 80% of cases occurring after the age of 60 ¹.

Risk factors include :

cigarette smoking : strongest environmental risk factor
diet rich in animal fats and protein
obesity
hereditary syndromes ⁶

Perhaps surprisingly there is only a weak if at all present association with heavy alcohol consumption ¹.

Pathology

Cancerous cells arise from pancreatic ductal epithelium. As the majority of tumours (90%) ¹ are not-resectable, this is mostly achieved with imaging (typically CT scan) although laparoscopy is often required to confirm resectability ^1-2. The key to accurate staging is assessment of the SMA and coeliac axis, which if involved exclude the patient from any attempted resection ^1-2

Histological types include

adenocarcinoma : majority
acinar cell carcinoma of pancreas
adenosquamous carcinoma of pancreas
undifferentied with osteoclasts giant cells

Location and classification

head and uncinate process: 2/3 cases
body and tai : 1/3 ¹

Staging

Refer to pancreatic ductal adenocarcinoma staging.

Radiographic features

Ultrasound

Findings are non-specific and include :

generally hypoechoic mass

CT

CT is the work-horse of pancreatic imaging. Typically ductal adenocarcinomas appear as poorly defined masses with extensive surrounding desmoplastic reaction. They enhance poorly compared to adjacent normal pancreatic tissue and thus appear hypodense on arterial phase scans in 75 - 90 % of cases, but may become isodense on delayed scans ¹ (thus the need for multiple phase scanning when pancreatic cancer is the clinical question)

CT correlates well with surgical findings in predicting unresectablitly (positive predictive value of 89 - 100% ³). The most important feature to assess locally is the relationship of the tumour to surrounding vessels (SMA and coeliac axis). If the tumour surrounds a vessel by more than 180 degrees then it is deemed T4 disease and is unresectable ³.

MRI

Signal characteristics include

T1 - hypo intense c.f. normal pancreas ⁵
T1 FS (fat suppressed) - hypo intense c.f. normal pancreas ⁵
T1 + C (Gd) - slower enhancement than normal pancreas, therefore dynamic injection with arterial phase imaging with fat saturation is ideal
T2 / FLAIR - variable (therefore not very useful) depending on the amount of reactive desmoplastic reaction ^1,5

Fluoroscopy

Barium meal / small bowel follow through

If large enough may demonstrate a reverse impression on the duodenum : Frostburg's inverted 3 sign, or a wide duodenal sweep

Treatment and prognosis

Most tumours are non resectable at diagnosis.

Surgery for Stage I and II (see staging of pancreatic cancer) does offer the chance of cure, with however high morbidity ( 20 - 30 %) and mortality (5%) ³. Resection is performed with a Whipple's operation.

Even when resection is possible, the majority of patients succumb to recurrence, with only a doubling of survival in operated patients ¹ from 5 to 10% at 5 years ⁴. Almost a quarter of patients are dead 12 months following diagnosis ⁴.