Pancreatic Cancer

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

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