• Clinical science

Pancreatic cancer

Summary

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, heavy 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. 20% of cases. The most commonly used surgical technique is the pancreaticoduodenectomy (Whipple procedure). Five-year survival rates range from 3–40% depending on the extent, spread, and resectability of the tumor.

Epidemiology

  • Age of onset: 60–80 years [1][2]
  • Incidence
    • ∼ 3% of all new cancers in the US
    • In 2020, 57,600 individuals in the US will be newly diagnosed with pancreatic cancer ( > )
  • Mortality: accounts for ∼ 8% of all cancer deaths in the US
  • High-risk groups [3][4]
    • African Americans
    • Individuals of Jewish ancestry

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Exogenous risk factors [5][6][7]

  • Smoking
  • Chronic pancreatitis (especially when present for more than 20 years)
  • High alcohol consumption
  • Type 2 diabetes mellitus
  • Obesity
  • Occupational exposure to chemicals used in the dry cleaning and metal working industries
  • H. pylori infection and excess stomach acid

Endogenous risk factors [5][8]

Clinical features

In most cases, there are no early symptoms suggestive of pancreatic cancer. [9]

Constitutional symptoms

  • Poor appetite
  • Weight loss
  • Weakness

Gastrointestinal symptoms

Hypercoagulability

A thrombosis of unknown origin may be caused by an undiagnosed malignancy (especially pancreatic cancer, but also pulmonary, and prostatic carcinoma, the "3P's").

The symptoms of pancreatic cancer may be similar to those of chronic pancreatitis. Differential diagnosis is difficult since carcinoma may be accompanied by pancreatitis.

Diagnostics

Blood

Imaging

Pathology

Location [10]

Pancreatic exocrine tumors [11]

Pancreatic endocrine tumors (neuroendocrine tumors/NET) [12]

Differential diagnoses

Pancreatic cyst

  • Overview
  • Clinical features
  • Diagnostics
    • CT scan: Cyst appears as a well-circumscribed hyperdense mass in comparison to the surrounding tissue.
    • ERCP: Cyst shows contrast-enhancement.
  • Treatment
    • Asymptomatic cyst: no surgical treatment
    • Symptomatic cyst: CT-guided, endoscopic, or surgical drainage

Other

The differential diagnoses listed here are not exhaustive.

Treatment

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.

Curative approach [13][14]

Surgery

Neoadjuvant or adjuvant chemoradiotherapy

Palliative approach [13][14]

Palliative chemotherapy

Pain management

Management of gastrointestinal complications

Complications

We list the most important complications. The selection is not exhaustive.

Prognosis

  • Very aggressive course [1]
  • Median survival for patients who undergo successful resection: ∼ 18 months (5-year survival rate: ∼ 20%) [15]