QuestionSBA
QuestionChoice
Bone marrow biopsy and serum protein electrophoresis are investigations used to evaluate for haematological malignancies, such as multiple myeloma, which do not explain the patients new onset diabetes or arm swelling.
10015794
d
Serum protein electrophoresis
QuestionChoice
While this may be useful in the context of symptoms suggestive of diabetes mellitus, it is not the single most important investigation here in view of the likely pancreatic cancer.
10015792
b
HbA1c
QuestionChoice
Multiparametric MRI is used in the evaluation of prostate cancer, which can cause back pain and weight loss, but it is not the most appropriate investigation in this case as it does not explain the other symptoms.
10015795
e
Multiparametric MRI
QuestionChoice
Bone marrow biopsy and serum protein electrophoresis are investigations used to evaluate for haematological malignancies, such as multiple myeloma, which do not explain the patients new onset diabetes or Trousseau's sign of malignancy.
10015793
c
Bone marrow biopsy
QuestionChoice
This presentation is suspicious for pancreatic cancer, which a CT scan can detect. This will also show involvement of local anatomy such as blood vessels or lymph nodes. The swelling in his left arm would be consistent with the Trousseau sign of malignancy, also known as migratory thrombophlebilitis, which presents as a tender nodule under the skin.
10015791
a
CT scan of the abdomen
QuestionComment
Only differential I had was lymphoma
41377
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Which lymphoma causes jaundice?
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Humerus H
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Botox Haemophilus
QuestionComment
Where does it talk about his new onset diabetes?? 
42570
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Pancreatic cancer can cause obstruction of the pancreatic duct, leading to autodigestion of the pancreas and thus *drum roll* diabetes. These questions make sense, but only with hind sight. I was staring at this with my jaw dropped ngl

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Htu2256
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According to NICE Guidelines, a fasting blood glucose level of 7.0 mmol/L (126 mg/dL) or higher is diagnostic for diabetes.
56584
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Serotonin Ventral
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Poisoning Contusion
QuestionComment
got the question right but the described location of lymphadenopathy is rubbish. Should be left supraclavicular
53112
QuestionComment
I think it's not lymphadenopathy since it's painful. The swelling is thrombophlebitis
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Catarina
QuestionComment
Virchow node is associated with gastric cancer and not pancreatic cancer, no?
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Goldfish
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Spinal Polyp
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I had no idea what this question was getting at

53428
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Juice Suture
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I genuinely thought the arm swelling was on the outside aspect of his arm, like a lump on the top of his deltoid or something. Never imagined they were talking about lymphadenopathy lol
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NewJeans
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what does the painful swellings have to do with the scenario? 
59696
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Hypertension Kinase
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first time I've ever felt smart
61978
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Positive Whiff Test
Concept
Chapter
# Summary

Pancreatic cancer, primarily adenocarcinomas, is the fifth leading cause of cancer in the UK with approximately 9,000 new diagnoses annually. Early symptoms such as malaise, abdominal pain, nausea, or weight loss are often non-specific, leading to a late diagnosis. Advanced disease may exhibit complications such as obstructive jaundice, newly diagnosed diabetes in older patients, unexplained pancreatitis, paraneoplastic syndromes, and others. Diagnostic investigations includes ultrasound, CT scan, MRI, MRCP, and endoscopic ultrasound, with biopsy if necessary. Management strategies depend on the stage of the disease; surgical resection, specifically pancreaticoduodenectomy, is the only potentially curative approach for localized disease, while palliative therapies are used for advanced cases.

# Definition

Pancreatic cancer is a malignant neoplasm originating from the pancreatic tissue. The pancreas is a glandular organ involved in both the digestive and endocrine systems of vertebrates. The most prevalent type of pancreatic cancer is pancreatic adenocarcinoma, which usually originates from the head of the pancreas.

# Epidemiology

- Pancreatic cancer ranks as the fifth most common cancer in the UK.
- Adenocarcinomas make up the majority of these cancers, with a poor 5-year survival rate (<5%).
- Each year in the UK, nearly 9,000 new pancreatic cancer cases are diagnosed.
- On average, a full-time GP will diagnose approximately one person with pancreatic cancer every 3-5 years.

# Aetiology

The exact cause of pancreatic cancer remains unknown. However, it is associated with several risk factors:

- Age: Pancreatic cancer is more prevalent in elderly individuals.
- Smoking: The risk significantly increases with tobacco use.
- Obesity: Overweight and obese individuals have a higher risk.
- Diabetes: Long-standing diabetes may increase risk.
- Chronic pancreatitis: Chronic inflammation of the pancreas can lead to cancer.
- Family history: Having a first-degree relative with pancreatic cancer increases the risk.
- Certain genetic syndromes: Genetic mutations linked to pancreatic cancer include BRCA2, Lynch syndrome, and familial atypical mole and melanoma (FAMMM) syndrome.

# Signs and Symptoms

Early-stage pancreatic cancer often presents with non-specific symptoms:

- Malaise
- Abdominal pain
- Nausea
- Weight loss
- Painless jaundice
- Courvoisier's sign - painless jaundice with a palpable gallbladder is usually indicative of a pancreatic or gallbladder malignancy (and less likely due to e.g. gallstones)

Advanced disease can present with complications including:

- Obstructive jaundice, often due to blockage of the common bile duct by a tumour in the pancreatic head. It may present with Courvoisier's sign.
- Diabetes mellitus, typically in an elderly patient with newly diagnosed diabetes and weight loss, may suggest a tumour in the body/tail of the pancreas.
- Pancreatic infiltration can lead to unexplained pancreatitis and pancreatic exocrine dysfunction with steatorrhoea.
- Paraneoplastic syndromes, such as Trousseau's syndrome (migratory thrombophlebitis), or marantic endocarditis.
- Disseminated intravascular coagulation (DIC)

Pancreatic cancer often metastasises early to the lung, liver, and bowel.

# Differential Diagnosis

Conditions with similar presentation to pancreatic cancer include:

- Chronic pancreatitis: Chronic abdominal pain, steatorrhoea, diabetes mellitus.
- Cholangiocarcinoma: Painless jaundice, weight loss, abdominal pain.
- Gastric cancer: Dyspepsia, weight loss, anorexia, nausea and vomiting.
- Hepatocellular carcinoma: Abdominal pain, weight loss, jaundice, hepatomegaly.

# Investigations

### NICE 2-week-wait criteria:

* Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 years and over and have jaundice.
* Consider an urgent  CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 years and over with weight loss and any of the following: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes.

Investigations for pancreatic cancer include:

- Initial assessment with abdominal ultrasound to detect tumours (>2cm), potential liver metastases and any dilation of the common bile duct.
- CT abdomen/pelvis for patients with a high clinical suspicion. This can predict surgical resectability and enables disease staging.
- Magnetic resonance cholangiopancreatography (MRCP) for details about the biliary ducts.
- Endoscopic ultrasound to detect small lesions (2-3mm) and for biopsy if needed.
- PET-FDG and MRI as adjuncts.

# Management

The only potentially curative treatment for pancreatic cancer is surgical resection. However, due to late presentation, only 15-20% of patients present with resectable disease.

Criteria for resection include:

- No evidence of superior mesenteric artery (SMA) or coeliac arteries involvement.
- No evidence of distant metastases.

The common surgical procedure for tumours in the head of the pancreas is the Kausch-Whipple procedure (radical pancreaticoduodenectomy). Adjuvant chemotherapy is offered post-surgery to patients who have recovered well.

In cases of locally advanced or metastatic disease, palliative therapy is the only option. This includes:

- Endoscopic stent insertion into the common bile duct.
- Palliative surgery if endoscopic stent insertion fails.
- Chemotherapy.
- Radiotherapy (only for localised advanced disease).

It is crucial to refer these patients to palliative care services for pain management and psychological support.

# NICE Guidelines

[Click here to see the NICE guidelines on pancreatic cancer](https://www.nice.org.uk/guidance/ng85)
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Pancreatic Cancer
Topic
7
General Surgery
Condition
493
Pancreatic cancer
UkmlaTopic
3
Cancer
Condition
494
Pancreatic cancer
UkmlaTopic
11
Gastrointestinal including liver
Condition
495
Pancreatic cancer
UkmlaTopic
25
Surgery
15702
A persistent, tender swelling in an arm, alongside unexplained weight loss and jaundice, warrants investigation with a CT scan, which may reveal underlying pancreatic cancer.
Presentation
564
Urinary symptoms
UkmlaTopic
10
Endocrine and metabolic
Presentation
565
Urinary symptoms
UkmlaTopic
12
General practice and primary healthcare
Presentation
566
Urinary symptoms
UkmlaTopic
13
Infection
Presentation
567
Urinary symptoms
UkmlaTopic
14
Medicine of older adult
Presentation
568
Urinary symptoms
UkmlaTopic
17
Neurosciences
Presentation
569
Urinary symptoms
UkmlaTopic
18
Obstetrics and gynaecology
Presentation
570
Urinary symptoms
UkmlaTopic
22
Renal and urology
Presentation
571
Urinary symptoms
UkmlaTopic
25
Surgery
A 75 year old man with no previous medical history presents with 7 kg of weight loss over the last three months. He has a tender palpable swelling in his left arm. He says that he has noticed a few similar swellings over the past few months. He appears jaundiced. His recent fasting blood glucose was 7.0 mmol/lL (normal range 3.5-5.5 mmol/L).

Which of the following investigations is most likely to reveal the underlying diagnosis?
a