Updated: 12/27/2021

Pancreatic Cancer

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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
  • 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
      • 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
  • Prognosis
    • Very poor prognosis

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(M2.ON.16.4699) 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?

QID: 108391
FIGURES:
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Pancreatic carcinoma

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Cholelithiasis

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Cholangiocarcinoma

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Hepatic carcinoma

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Autoimmune hepatitis

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(M2.ON.16.4672) 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?

QID: 107186
FIGURES:
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Elevated hemoglobin and hematocrit

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Elevated CA19-9

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Elevated Beta-HCG

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Elevated Alpha fetoprotein

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Elevated PSA

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