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Updated: Oct 1 2019

Pancreatic Cancer

  • 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
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