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TUMOURS OF THE PANCREAS

Beta-cell tumors or Nesidoblastomas:
These tumours, which originate from the beta-cells, produce an excess of insulin, hence they are known as insulinomas. In a typical case, the patient presents with Whipple’s triad, characterized by a complex of three symptoms viz.
  • Attack of nervous or gastrointestinal disturbances, coming on in a fasting state (e.g. in the morning) or after an exercise, when
  • The fasting blood sugar is less than 50mg percent and
  • The attack is relieved immediately by the ingestion of glucose
classification of pancreatic tumours
Pathology:
Pathologically the tumours may be:

Benign: Adenoma or adenomatosis (i.e. multiple adenoma) – 80%
Carcinoma: 20 %

  • Carcinoma of the head of pancreas: The tumour arises form the glandular epithelium of the head. It is of spheroidal cell carcinoma. The tumour is characterized by:
    • Scirrhous (i.e. hard) nature
    • Rapid growth and early metastasis
    • Rapidly progressing obstructive jaundice, leading to the death from cholaemia, because of the compression of the common bile duct.
  • Periampullary carcinoma: Cancers may arise in the:
    • Termination of the common bile duct or pancreatic duct
    • Common Ampulla of Vater
    • Duodenal papilla or the duodenal mucosa adjacent to the papilla

    On exploration, it is usually impossible to decide in which of the above structures the tumour had originated. This is why these tumours are collectively termed as periampulllary cancers, i.e. cancers around the ampulla of Vater. The tumours are closely related to the head of the pancreas and so they are considered together with cancers of the pancreatic head. These tumours are of columnar-cell type. They are characterized by:
    • Encephaloid (i.e. softer) nature, thus more likely to undergo central degeneration
    • Slow growth and late metastasis
    • Early jaundice which progresses at a lesser speed than that associated with cancers of the head proper
    • Anaemia due to bleeding from the tumour in the duodenum
  • Carcinoma of the body and/or tail: When the tumour arises from the glandular epithelium, it is of spheroidal cell type. When it arises from the cells lining the excretory duct, it is of columnar-cell type. These tumours usually differ from the above types in the following points:
    • Bigger size
    • More wide spread metastasis (death is due to liver metastasis)
    • Often painful
Spread:
  • Direct spread: Cancers arising in the pancreatic tissue proper tend to spread more quickly than the periampullary cancers. Again cancers of the body and tail spread quickly than those of the head. Coming out of the pancreatic tissue, the growth may spread to the bile duct, duodenum or the pyloric antrum. Growth of the body and tail may infiltrate into the stomach wall, transverse mesocolon or celiac plexus, causing pain
  • Lymphatic spread:
    • From the head: to the nodes in the capsule of the head, and then to the nodes on the bile duct and those at the porta hepatic. Portal metastasis is relatively late
    • From the body and tail: to the nodes along the upper border of the pancreas and then to the celiac and splenic node
  • Venous spread: These are the commoner with cancers of the body and tail. Spread occurs to the liver by the way of the portal vein. Usually the metastasis is motile and small. Rarely there may be lung metastasis
  • Transcoelomic spread: Peritoneal dissemination may occur in some cases
Symptoms:
  • Obstructive jaundice: is the most important presenting feature of the cancers of the head, because of the obstruction to the common bile duct. The jaundice is progressive and the patient may turn green in colour. In some cases the periampullary carcinoma, the jaundice may show periodical waxing and waning. This is because of the periodic necrosis, occurring in some part of the growth (since it is soft in nature), allowing the pent up bile to be excreted into the duodenum. During these periods, the stools may get coloured
  • Itching: this is often distressing and is due to the circulating bile salts
  • Pain: though the characteristic presentation of the head cancer is stated to be a painless jaundice, many of the patients get pain sometimes or other. The pain is of variable nature and intensity, and may precede or follow the jaundice. Cancers of the body and tail are painful because of:
    • Early involvement of celiac plexus
    • Spreading along nerve trunks
  • Gastroduodenal symptoms: Anorexia is fairly common, vomiting is a late symptom.
  • Diarrhea may occur in some cases and may be due to:
    • Pancreatic insufficiency in case of head cancers due top the obstruction of the pancreatic duct (steatorrhoea)
    • Involvement of the transverse colon by growths of the body and tail
  • Diabetes: there is a reciprocal relationship between diabetes and pancreatic cancers:
    • Diabetes is common in patients with cancers of the pancreas
    • Pancreatic cancers are about 10 times more frequent I diabetics than the normal people
  • Melena: may occur, especially in periampullary cancers that erode into the duodenum
  • Loss of weight: is a constant feature
  • Anaemia: more sever in case of the periampullary cancers because of oozing into the duodenum (occult blood in stool)
  • Thrombophlebitis migrans: there is a fleeting thrombophlebitis in different superficial veins, one after the other called the Trosseau’s sign. This is common with the cancers of the body and tail
Physical signs:
  • The gall bladder is often palpable in accordance with Courvoisier law and this may be due to:
    • Biliary obstruction, resulting in dilation of the biliary channel, sometimes announcing the hydrohepatosis. The palpable liver is smooth i.e. cholestatic liver (on exploration, the liver looks green)
  • Metastasis: due to metastasis there is hard and nodular liver
  • The tumour itself is seldom palpable, excepting very rarely, e.g. a large growth in the body or tail
  • Ascites is a common feature, particularly in late case. This may be due to:
    • Compression or invasion of the portal vein by the growth
    • Portal obstruction within the liver
    • Peritoneal dissemination
Differences between cancers of the head and periampullary cancers:
Differentiation is usually impossible but the following points may be helpful:
  • Jaundice: After the appearance pf jaundice, the duration of the life is usually longer, and the health better maintained, in periampullary cancers.
    The jaundice may show waxing and waning in case of periampullary cancers, and may occasionally disappear completely for some period
  • Pain: less common and less severe in periampullary cancers
  • Melena: common with periampullary cancers because they tend to ulcerate in the duodenum
  • Gall bladder: more often palpable in periampullary cancers
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This article has been written by Dr. M. Javed Abbas.
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20:33 09/02/2003