Pancreatic Cancer - Oncology - Medbullets Step 1

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

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum
Total (recumbent)	6.0-7.8 g/dL
Albumin	3.5-5.5 g/dL
Globulin	2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma	.5-5.0 μU/mL
Thyroidal iodine (¹²³I) uptake	8%-30% of administered dose/24h
Thyroxine (T4), serum	5-12 μg/dL
Triglycerides, serum	35-160 mg/dL
Triiodothyronine (T3), serum (RIA)	115-190 ng/dL
Triiodothyronine (T3) resin uptake	25%-35%
Urea nitrogen, serum	7-18 mg/dL
Uric acid, serum	3.0-8.2 mg/dL

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²

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(M1.ON.66) A 70-year-old male visits his primary care physician because of progressive weight loss. He has a 20-year history of smoking 2 packs of cigarettes a day and was diagnosed with diabetes mellitus 6 years ago. After physical examination, the physician tells the patient he suspects adenocarcinoma at the head of the pancreas. Which of the following physical examination findings would support the diagnosis: Review Topic

QID: 101123

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Lymphadenopathy of the umbilicus

(0/9)

Acanthosis nigricans

22%

(2/9)

Palpable gallbladder

78%

(7/9)

Renal artery bruits

(0/9)

Splenomegaly

(0/9)

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SUBMIT RESPONSE 3