• 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, 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.

Epidemiology

  • 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%

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[5][6][7][8][2]

Clinical features

References: [4][3][9][10]

Diagnostics

Blood

Imaging

  • First test: usually either contrast-enhanced abdominal CT or ultrasound → if ultrasound reveals a pancreatic mass → subsequent CT
    • Poorly defined, hypodense/hypoechoic and hypovascular mass
    • Double-duct sign; : With increasing size, tumors of the pancreatic head may block bile drainage in both the common bile duct and the pancreatic duct, leading to dilatation of both structures.
  • 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)

References:[9][4]

Pathology

References:[11][4]

Differential diagnoses

  • Pancreatitis
  • 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
    • Treatment
      • Asymptomatic cyst: no surgical treatment
      • Symptomatic cyst: CT-guided, endoscopic, or surgical drainage

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

Surgery

Neoadjuvant or adjuvant chemoradiotherapy

  • To reduce tumor size, improve symptoms, and prolong life
  • Chemotherapy or radiation therapy without surgery cannot cure the patient.

Palliative approach

  • Analgesia according to the WHO step-by-step plan
    • Early consultation with a pain therapist for optimizing the need of coanalgesics and adjuvants may be indicated.
  • 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

References:[4][3][12][10][13]

Complications

References:[4][10][12]

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

Prognosis

  • The overall 5-year survival rate is 7%, but mainly depends on the stage of disease.
  • Median survival for patients who undergo successful resection: ∼ 12–19 months, with a 5-year survival rate of 15–20%
  • A metastatic pancreatic cancer has a 5-year survival rate of ∼ 2%.

References:[14][1][15][4]