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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

  • Carcinomas

    • Most common pancreatic neoplasm

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

    • Pancreatic carcinomas account for 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

    • Pancreatic cysts are common, but 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

    • Gallstones, 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 10–15% 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 or, when the lesion is in the tail, located in the left upper quadrant of the abdomen

    • 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 is common and may be associated with ...

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