Pancreatic Cancer

last authored: Aug 2009, David LaPierre

Introduction

Pancreatic adenocarcinomas are dangerous malignancies with an increasing incidence in the Western world. Peak rates occur at ages 50-70, with male:females affected in a 2:1 ratio.

The Case of...

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Causes and Risk Factors

Risk factors include:

age
male gender
carcinogens
cigarette smoking
hereditary or chronic pancreatitis
potentially a high-fat diet

Occupational exposure to beta napthylamine and benzidine are clear risk factors for a few.

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Pathophysiology

Pancreatic adenocarcinomas begin in the head (55%), body (25%), or tail (15%)of the pancreas. Periampullary carcinomas begin around the ampulla of Vater (5%), but can also begin the bile duct or duodenum.

Endocrine tumours can cause a number of syndromes due to hormonal secretion.

Histological studies show 90% of malignancies being ductal carcinoma, 7% acinar cell carcinoma, 2% cystic carcinoma, and 1% of connective tissue origin.

Pancreatic cancers spread early and aggressively. They may grow directly into the bowels, portal vein

via the lymphatics to the peritoneum and regional nodes, and by the vasculature (portal vein) to liver and lung. They may also spread along nerves.

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Signs and Symptoms

Pancreatic carcinoma can be an insidous disease, and often is advanced at time of diagnosis.

history
physical exam

History

Abdominal pain, when present, tends to be constant and radiating to the back. Other symptoms can include:

jaundice
nausea, vomiting, and anorexia from duodenal obstruction
weight loss
steatorrhea
back pain:
emotional problems such as depression

Physical Exam

Obstructive jaundice or a large, palpable gallbladder may be present.

Less common presenting symptoms include migratory thrombophlebitis, acute pancreatitis, diabetes, paraneoplastic syndromes such as Cushing's, hypercalcemia, GI bleeding, splenic-vein thrombosis, and a palpable abdominal mass.

ascites (suggests multiple seedings, or massive lymphatic blockade)

Virchow's node

congestive hepatomegaly

Courvoisier's node: distended, painless galbladder

Sister Mary Joseph sign:

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Investigations

lab investigations
diagnostic imaging

Lab Investigations

Tumour markers have been disappointing, although the tumour marker CA 19-9 has a sensitivity of 80-90% and a specificity of 85-95% in people with suggestive signs and symptoms. It is not useful for screening.s

Diagnostic Imaging

Diagnosis is frequently suggested by the presence of a mass on imaging. CT and MRI are best for defining a mass and assessing for liver metastasis.

Ultrasound can reveal a mass in the head of the pancreas and a distended biliary tree. It is risk-free and accessible. Assess for ascites, liver metastasis, CBT dilatation, and potentially the mass.

ERCP can be used to show main pancreatic duct stricture in almost all cases where a mass is not otherwise found.

EUS is the most accurate diagnostic and staging modality

Barium swallow can show a widened duodenal loop with a medial filling defect, or the reversed 3 sign.

If surgery is indicated by the above imaging, laparoscopy should be performed before a large incision to prevent futile surgery in cases of micro

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Differential Diagnosis

Other diagnoses to consider include:

pancreatitis

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Treatments

Curative treatment is available to those with small tumours and no evidence of spread:

Whipple's pancreatico-duodenectomy

For advanced cancer stage, or due to other co-morbidities is 20% for cancers originating in the head and 10% for cancers beginning in the neck and body. Palliative treatment should be provided to patients with non-resectable pancreatic cancer. Treatments include: