Pancreatic Adenocarcinoma

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • 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

Imaging Findings

• • 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

• • 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

Rule Out

• • Chronic pancreatitis

  • Other periampullary neoplasms:

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

  • Retroperitoneal lymphoma

  • Retroperitoneal sarcoma

• • 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

When to Admit

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