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 3% of all cancers and 7% of cancer deaths

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

• Cystic neoplasms

  • Account for < 10% of pancreatic neoplasms

  • 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 or trauma

  • 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 1–3 regional lymph nodes

  • N2: metastasis to ≥ 4 regional lymph nodes

  • M1: distant metastasis

Demographics

• The incidence of pancreatic cancer is increasing, and over the next two decades it is expected to surpass colorectal cancer as the second leading cause of cancer-related deaths in the United States

• Risk factors for pancreatic carcinoma

  • Age

  • Obesity

  • Tobacco use (thought to cause 20–25% of cases)

  • Heavy alcohol use

  • Chronic pancreatitis

  • Diabetes mellitus

  • Prior abdominal radiation

  • Family history

  • Gastric ulcer (possibly)

  • Exposure to arsenic, cadmium

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

• In 5–10% of patients, pancreatic cancer occurs as part of a hereditary syndrome, including

  • Familial breast cancer

  • Hereditary pancreatitis

  • Familial atypical multiple mole melanoma

  • Peutz-Jeghers syndrome

  • Ataxia-telangiectasia

  • Lynch syndrome

Clinical Findings

Symptoms and Signs

• Pain

  • Present in > 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

• Hyperglycemia and decreases in subcutaneous abdominal fat and serum lipid levels have been reported to precede a diagnosis of pancreatic cancer

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

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