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Updated: Dec 27 2021

Pancreatic Cancer

  • 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
      • 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
  • Prognosis
    • Very poor prognosis
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