- Clinical science
Pancreatic cancer is the fourth leading cause of cancer deaths in the US and typically affects older individuals in the sixth to eighth decades of life. Underlying risk factors include smoking, obesity, alcohol consumption, and chronic pancreatitis. Pancreatic carcinomas are mostly ductal adenocarcinomas and frequently located in the pancreatic head. The disease is commonly diagnosed at an advanced stage because of the late onset of clinical features (e.g., epigastric pain, painless jaundice, and weight loss). In many cases, the tumor has already spread to other organs (mainly the liver) when it is diagnosed. Treatment is often palliative as surgical resection is only possible in approx. 15% of cases. The most commonly used surgical technique is the pancreaticoduodenectomy (“Whipple procedure”). Five-year survival rates range from 1–20% depending on the extent, spread, and resectability of the tumor.
- Sex: ♂ > ♀
- Age of onset: 60–80 years
- More common in African Americans
- Accounts for ∼ 3% of all cancers in the US and ∼ 7% of cancer deaths
- The average lifetime risk: ∼ 1.5%
Epidemiological data refers to the US, unless otherwise specified.
- Chronic pancreatitis
- High alcohol consumption
- Type 2 diabetes
- Occupational exposure to chemicals used in the dry cleaning and metal working industries
- Cirrhosis of the liver
- H. pylori infection; excess stomach acid
- Inherited genetic syndromes (10% of pancreatic cancers)
- Familial pancreatic carcinoma
- Familial pancreatitis (mutations in the PRSS1 gene)
- Peutz-Jeghers syndrome
- Familial atypical multiple mole melanoma (FAMMM) syndrome
- Hereditary breast and ovarian cancer syndrome (BRCA1 and BRCA2 mutations)
- Von-Hippel-Lindau syndrome
- Neurofibromatosis type 1
- Multiple endocrine neoplasia type 1
- Often no early signs present!
- Belt-shaped epigastric pain which may radiate to the back
- Weight loss, nausea, weakness, poor appetite
- Diarrhea (possibly steatorrhea secondary to exocrine pancreatic insufficiency)
- Superficial thrombophlebitis (in 10% of cases, also called Trousseau syndrome or Thrombophlebitis migrans)
- Thrombosis (e.g., phlebothrombosis, splenic vein thrombosis)
- Impaired glucose tolerance (rarely)
- The symptoms of pancreatic cancer may be similar to those of chronic pancreatitis. Differential diagnosis is difficult since carcinoma may be accompanied by pancreatitis!
- No screening tests available
Tumor markers: CA 19-9 and CEA
- Used to monitor the progression of cancer and treatment efficacy
- Possibly ↑ lipase
- First test: usually either contrast-enhanced abdominal CT or ultrasound → if ultrasound reveals a pancreatic mass → subsequent CT
- Endoscopic or magnetic retrograde cholangiopancreatography (ERCP/MRCP): to rule out choledocholithiasis and/or if biliary decompression is indicated; , e.g., in case of palliative treatment to alleviate jaundice
Endoscopic ultrasound (EUS)
- Used when other diagnostic tests are inconclusive or to perform fine needle aspiration
- Findings similar to transcutaneous ultrasound
Fine needle aspiration
- Not routinely performed
- Can help differentiate pancreatic cancer from pancreatitis (e.g., chronic or autoimmune)
- Can be done via EUS (preferred) or percutaneously (US or CT-guided)
Pancreatic exocrine tumors (95%)
- Mostly ductal adenocarcinoma
- Less common: acinar adenocarcinoma (acinar cells produce digestive enzymes) and others
- Pancreatic endocrine tumors (neuroendocrine tumors/NET, < 5% of tumors)
- Metastasis (e.g., breast carcinoma, bronchial carcinoma)
- Pancreatic pseudocyst
Pancreatic cyst: Epithelium-lined cyst, filled with serous or mucous liquid, often associated with the rare von-Hippel-Lindau syndrome; can be benign, precancerous or cancerous.
- Clinical features: abdominal pain, back pain, jaundice, and in case of infection, fever and sepsis
- CT scan: cyst appears as a well-circumscribed hyperdense mass in comparison to the surrounding tissue. Pancreatic cancer, on the other hand, is hypodense.
- ERCP: cyst shows contrast-enhancement
- Asymptomatic cyst: no surgical treatment
- Symptomatic cyst: CT-guided, endoscopic, or surgical drainage
The differential diagnoses listed here are not exhaustive.
As the only curative treatment option for pancreatic cancer is surgical resection, patients with operable tumors; (∼ 20%) are always recommended for surgery. If surgical tumor resection is not possible or distant metastasis is present, a palliative approach is chosen.
Pancreatic head carcinoma: ("Whipple procedure"; method of choice)
- Resection of pancreatic head, distal stomach, duodenum, gallbladder, and common bile duct
- Reconstruction by enteroenterostomy or Roux-en-Y anastomosis
- (Traverso-Longmire procedure): a modification of the Whipple procedure that preserves the gastric antrum, the pylorus and a small part of the duodenum (anastomosed to the jejunum) to provide a more physiologic stomach emptying
- Pancreatic body and tail carcinoma
Neoadjuvant or adjuvant chemoradiotherapy
- To reduce tumor size, improve symptoms, and prolong life
- Chemotherapy or radiation therapy without surgery cannot cure the patient.
- Analgesia according to the WHO step-by-step plan
- Cholestasis : ERCP with stent implantation
- Gastroenterostomy: best supportive care in patients with gastric outlet stenosis. The stomach is anastomosed with the small intestine bypassing the duodenum.
- Percutaneous endoscopic gastrostomy (PEG) tube as a relief tube: indicated for severe palliative patients with chronic ileus and subileus that are inoperable
- Lymphogenic and hematogenous metastasis
- Gastric outlet stenosis
- Stenosis of the common bile duct (cholestasis)
- Other complications
We list the most important complications. The selection is not exhaustive.