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Key Features

Essentials of Diagnosis

  • Obstructive jaundice (may be painless)

  • Enlarged gallbladder (may be painful)

  • Upper abdominal pain with radiation to back, weight loss, and thrombophlebitis are usually late manifestations

General Considerations

  • Adenocarcinomas

    • Most common pancreatic neoplasm

    • About 75% are in the head and 25% in the body and tail

    • Pancreatic carcinomas comprise 2% of all cancers and 5% of cancer deaths

  • Neuroendocrine tumors account for 1–2% of pancreatic neoplasms

  • Cystic neoplasms

    • Only 1% of pancreatic cancers

    • May be mistaken for pseudocysts

    • Should be suspected when a cystic lesion in the pancreas is found in the absence of a history of pancreatitis

    • Serous cystadenomas are benign

    • However, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary tumors, and cystic islet cell tumors may be malignant

  • Adenocarcinoma staging is by the TNM classification

    • Tis: carcinoma in situ

    • T1a: tumor limited to the pancreas, ≤ 0.5 cm in greatest dimension

    • T1b: tumor > 0.5 cm and < 1 cm

    • T1c: tumor 1–2 cm

    • T2: tumor limited to the pancreas, > 2 cm and ≤ 4 cm in greatest dimension

    • T3: tumor > 4 cm in greatest dimension

    • T4: tumor involves the celiac axis, superior mesenteric artery, or common hepatic artery regardless of size

    • N1: metastasis to one to three regional lymph nodes

    • N2: metastasis to four or more regional lymph nodes

    • M1: distant metastasis

Demographics

  • Risk factors for pancreatic carcinoma

    • Age

    • Obesity

    • Tobacco use

    • Heavy alcohol use

    • Chronic pancreatitis

    • Diabetes mellitus

    • Prior abdominal radiation

    • Family history

    • Gastric ulcer (possibly)

    • Exposure to arsenic, cadmium

  • About 7–8% of pancreatic cancer patients have a first-degree relative with pancreatic cancer, compared with 0.6% of control subjects

Clinical Findings

Symptoms and Signs

  • Pain

    • Present in over 70%

    • Often vague and diffuse

    • Located in the epigastrium when lesion is in the pancreatic head or body; or located in the left upper quadrant when lesion is in the tail

    • Radiation into the back is common and sometimes predominates

    • Sitting up and leaning forward may afford some relief, which usually indicates extrapancreatic spread and inoperability

  • Diarrhea, perhaps from maldigestion, is an occasional early symptom

  • Weight loss commonly occurs late and may be associated with depression

  • Occasionally, acute pancreatitis or new-onset diabetes mellitus is the presentation

  • Jaundice is usually due to biliary obstruction in the pancreatic head

  • A palpable gallbladder is indicative of obstruction by neoplasm (Courvoisier law), but there are frequent exceptions

  • A hard, fixed, occasionally tender mass may be present

  • In advanced cases, a hard periumbilical (Sister Mary Joseph's) nodule (lymph node) may be palpable

  • Migratory thrombophlebitis is a rare sign

Differential Diagnosis

  • Choledocholithiasis

  • Pancreatic pseudocyst or cystic neoplasm

  • Carcinoma of the biliary tract

  • Biliary stricture

  • Hepatocellular carcinoma

  • Primary sclerosing cholangitis

  • Primary biliary cholangitis

Diagnosis

Laboratory Tests

  • Mild ...

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