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  • • Marked weight loss, abdominal pain and jaundice are common presenting symptoms

    • Pancreatic mass often visible on CT scan

    • Biliary and duodenal obstruction from tumor growth may occur if located in the pancreatic head

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Epidemiology

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  • • Incidence and mortality rates are roughly the same, underscoring the abysmal prognosis—5-year survival, < 3%

    • Third leading cause of cancer in men between ages 35 and 54

    • Risk factors include:

    • -Cigarette smoking

      -Dietary consumption of meat (especially fried meat) and fat

      -Previous gastrectomy (> 20 years earlier)

      -Race (In the United States, but not in Africa, blacks are more susceptible than whites.)

    • The peak incidence is in the fifth and sixth decades

    • In 67% of cases, the tumor is located in the head of the gland; the remainder occurs in the body or tail

    • Early local extension to contiguous structures; metastases to regional lymph nodes and the liver; and later, metastases to lungs, peritoneum, and distant lymph nodes

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Symptoms and Signs

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  • • Weight loss

    • Abdominal pain

    • Back pain (worse prognosis)

    • Nausea/vomiting

    • Migratory thrombophlebitis

    • Palpable epigastric mass

    • Obstructive jaundice, often with pruritus and/or cholangitis

    • Palpable, nontender gallbladder in the right upper quadrant (Courvoisier sign)

    • Sudden onset of diabetes mellitus in 25% of patients

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Laboratory Findings

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  • • Elevated alkaline phosphatase

    • Elevated serum bilirubin

    • Elevated serum levels of the tumor marker CA 19-9; sensitivity is too low to use as a screening tool

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Imaging Findings

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  • CT scan

    • -Pancreatic mass

      -Dilated pancreatic duct and/or bile duct

      -Allows determination of resectability in most cases

    ERCP

    • -In patients with a typical clinical history and a pancreatic mass on CT, ERCP is unnecessary

      -Stenosis or obstruction of the pancreatic duct and/or bile duct ("double-duct sign")

    Upper GI series

    • -Determines patency of the duodenum

      -Useful in deciding whether a gastrojejunostomy will have to be performed

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  • • Tumors of the body and tail cause biliary and duodenal obstruction less commonly than tumors in the head

    • Percutaneous aspiration of pancreatic mass risks tumor spread; contraindicated in surgical candidates

    • CA 19-9 useful to follow the results of treatments; after complete resection, levels rise again with recurrence.

    • CT findings suggesting unresectability:

    • -Local tumor extension

      -Contiguous organ invasion

      -Distant metastases

      -Involvement of the superior mesenteric or portal vessels

      -Ascites

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Rule Out

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  • • Chronic pancreatitis

    • Other periampullary neoplasms:

    • -Carcinoma of the ampulla of Vater, distal common bile duct, or duodenum

    • Retroperitoneal lymphoma

    • Retroperitoneal sarcoma

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  • • CT scan

    • ERCP or endoscopic US if pancreatic cancer suspected but mass not visualized on CT scan

    • If mass determined unresectable by CT scan, percutaneous or endoscopic US-guided needle aspiration for cytologic confirmation of diagnosis

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When to Admit

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  • • Severe abdominal pain

    • Duodenal obstruction prohibiting ...

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