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Snapshot
  • A 72-year-old man presents to his primary care physician with generalized fatigue and mild abdominal pain. He has had a 25-pound weight loss over the course of 2 months. He has a past medical history of alcohol use disorder complicated by chronic pancreatitis. He also has been smoking 1 pack of cigarettes for the past 40 years. Physical examination is notable for scleral icterus and abdominal tenderness to palpation in the epigastric region. An abdominal ultrasound demonsrates a pancreatic mass compressing the biliary system. 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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Questions (7)
Lab Values
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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(M2.ON.4699) A 72-year-old man presents to clinic complaining of 3 months of weight loss, epigastric pain after meals, diarrhea, and acholic stools. On physical exam he has jaundice and a right upper quadrant mass, but no abdominal tenderness. He has a palpable left supraclavicular node. He also has multiple tender areas of inflamed skin on his chest wall and legs. The patient states that these patches change location over time. CT scan of his abdomen is seen in Figure A. What is the most likely diagnosis? Review Topic

QID: 108391
FIGURES:
1

Pancreatic carcinoma

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2

Cholelithiasis

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Cholangiocarcinoma

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4

Hepatic carcinoma

0%

(0/0)

5

Autoimmune hepatitis

0%

(0/0)

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(M2.ON.4672) A 43-year-old man presents to his primary care physician with a 2-month history of weight loss, diarrhea, and dull abdominal pain. Vital signs are unremarkable. Physical exam shows a thin male, with scleral icterus. Abdominal exam is notable for mild epigastric tenderness. Laboratory studies are remarkable for an elevated blood glucose. An abdominal CT scan is shown in Figure A. Which of the following finding are most likely in this patient? Review Topic

QID: 107186
FIGURES:
1

Elevated hemoglobin and hematocrit

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2

Elevated CA19-9

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3

Elevated Beta-HCG

0%

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4

Elevated Alpha fetoprotein

0%

(0/0)

5

Elevated PSA

0%

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