Snapshot A 69-year-old man presents to the emergency department with generalized fatigue and abdominal pain. He has had a 20-pound weight loss over the course of 3 months. He has a past medical history of alcohol use disorder and longstanding diabetes. He also has been smoking 1 pack of cigarettes for the past 50 years. Physical examination is notable for scleral icterus and abdominal tenderness to palpation in the epigastric region. CT abdomen with and without contrast demonstrates a mass at the head of the pancreas. Introduction Overview malignancy affecting the pancreas types adenocarcinoma > 90% of pancreatic cancers are adenocarcinoma arising from the pancreatic ducts most tumors arise in the head of the pancreas (~75%) neuroendocrine Epidemiology incidence 4th leading cause of cancer in the United States demographics > 60 years of age risk factors smoking heavy alcohol consumption obesity chronic pancreatitis long standing diabetes Etiology likely from accumulation of various genetic mutations e.g., KRAS2 and CDKN2A Pathogenesis pancreatic adenocarcinoma begins in the pancreatic ductal epithelium premalignant lesions (e.g., pancreatic intraepithelial neoplasia) then progress to malignant lesions secondary to accumulation of genetic mutations Prognosis very poor prognosis Presentation Symptoms generalized fatigue abdominal pain sequela of biliary obstruction in tumors arising from the pancreatic head jaundice dark urine Physical exam unexplained weight loss hepatomegaly Courvoisier sign palpable gallbladder in pancreatic cancers involving the head of the pancreas Imaging Abdominal ultrasound indication initial imaging study in patients who present with jaundice has a high sensitivity (> 95%) in detecting a pancreatic mass Abdominal CT scan indication initial imaging study in patients who present with abdominal pain and weight loss but without jaundice confirms the presence of a pancreatic mass if it is found in the abdominal ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) indication performed if abdominal ultrasound and abdominal CT scan do not demonstrate an obvious cause of biliary obstruction can obtain a tissue diagnosis for small tumors that cannot be appreciated on the above imaging modalities Endoscopic ultrasonography indication can be used to obtain a tissue diagnosis not always necessary if a resectable mass is demonstrated on abdominal CT scan Studies Serum labs CA 19-9 a tumor marker lipase AST, ALT, and alkaline phosphatase may be elevated if the malignancy compresses the biliary system Differential Acute pancreatitis differentiating factor no pancreatic mass seen Gastric cancer differentiating factor mass seen in the stomach Treatment Treatment depends on the stage of the pancreatic cancer Surgical Whipple procedure indication in resectable pancreatic cancer Complications Obstructive cholestasis Gastric outlet obstruction Diabetes Migratory thrombophlebitis