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. Occasionally, small, potentially resectable pancreatic lesions can be discovered on imaging. These can represent benign, precancerous, or malignant lesions. Management varies by lesion type, e.g., , . Screening is not routinely performed but is recommended for select high-risk individuals.
- Age of onset: : 60–80 years 
- Mortality: accounts for ∼ 8% of all cancer deaths in the US
High-risk groups 
- African Americans
- Individuals of Jewish ancestry
Epidemiological data refers to the US, unless otherwise specified.
Exogenous risk factors 
- Smoking (strongest risk factor)
- Chronic pancreatitis (especially when present for more than 20 years)
- High alcohol consumption
- Type 2 diabetes mellitus
- Occupational exposure to chemicals used in the dry cleaning and metalworking industries
- Possibly infections with:
Endogenous risk factors 
- Age > 50 years
Inherited genetic syndromes (10% of pancreatic cancers)
- 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
- Familial pancreatic carcinoma
- Hereditary pancreatitis (mutations in the PRSS1 gene)
- Peutz-Jeghers syndrome
In most cases, there are no early symptoms suggestive of pancreatic cancer. 
- Poor appetite
- Weight loss
- Belt-shaped epigastric pain which may radiate to the back
- Malabsorption, diarrhea (possibly steatorrhea secondary to exocrine pancreatic insufficiency)
- Jaundice caused by obstruction of extrahepatic bile ducts (especially in tumors of the pancreatic head)
- Impaired glucose tolerance (rarely)
- Trousseau syndrome: superficial thrombophlebitis (in 10% of cases)
- Thrombosis (e.g., phlebothrombosis, splenic vein thrombosis)
In the majority of instances, pancreatic cancer is diagnosed in symptomatic patients once it has already spread regionally or distally and is no longer resectable. If identified at an early stage (e.g., as an incidentaloma), lesions may be resectable. Initial testing is guided by clinical presentation. Consider screening for high-risk asymptomatic individuals (see “Prevention”). 
- Unexplained epigastric pain, RUQ pain, and/or jaundice
- High clinical suspicion for abdominal malignancy : Consider CT abdomen and pelvis with IV contrast as initial imaging.
- Indeterminate pancreatic lesions on imaging (e.g., found during workup or screening, including ) 
- Confirmed pancreatic malignancy
Pancreatic should be investigated early and evaluated for curative resection.
Initial diagnostic imaging 
Used to identify potentially malignant lesions and evaluate for resectability
- Ultrasound abdomen: often the initial recommended test, especially if the patient presents with jaundice
- CT abdomen (with PO water and IV contrast; pancreas-specific triphasic protocol)
- MRI abdomen: alternative if CT is contraindicated 
- Findings of pancreatic adenocarcinoma (See “Pancreatic cystic lesions” for other findings.)
Routine laboratory studies 
Findings are variable and nonspecific but may show abnormalities caused by pancreatic cancer or related complications.
- Obtain CBC, BMP, pancreatic enzymes, liver chemistries, and liver function parameters.
- Increased lipase and/or can occur due to the presence of obstructive tumors (typically of the pancreatic head).
- Other abnormalities may occur due to:
Diagnostic confirmation 
Endoscopic ultrasound (EUS)
- Used to confirm the diagnosis and determine resectability when other studies are inconclusive
- Can be combined with for tissue sampling
- Tissue sampling: required for most patients with pancreatic masses or suspicious on imaging ; 
- ERCP: usually used when biliary decompression is indicated
- Tumor markers: not recommended for diagnosis or screening ; 
Imaging for preoperative staging 
Once the diagnosis is confirmed, pancreatic cancer should be staged to determine management. The American Joint Committee for Cancer (AJCC) TNM classification is currently the standard staging system used in clinical practice.
|Pancreatic cancer staging system |
|T1||Maximum tumor diameter ≤ 2 cm|
|T2||Maximum tumor diameter > 2 cm and ≤ 4 cm|
|T3||Maximum tumor diameter > 4 cm|
|T4||Tumor involves the celiac axis, common hepatic artery, and/or superior mesenteric artery|
|N0||No regional lymph node involvement|
|N1||Involvement of 1–3 regional lymph nodes|
|N2||Involvement of ≥ 4 regional lymph nodes|
|M0||No distant metastases|
|Stage IA||T1, N0, M0|
|Stage IB||T2, N0, M0|
|Stage IIA||T3, N0, M0|
|Stage IIB||Up to T3, N1, M0|
|Stage III||Up to T3, N2, M0 or T4, any N, M0|
|Stage IV||Any T, any N, M1|
- Pancreatic exocrine tumors: originate from and ducts 
- Pancreatic endocrine tumors: originate from (See “Pancreatic neuroendocrine tumors” for details.)
General principles 
- Establish goals of care via shared-decision making.
- Multidisciplinary care is typically required.
- Treatment intent depends on:
- Tumor resectability
- Patient performance status and comorbidity profile
- Generally poor prognosis; all patients should be considered for clinical trials
- Provide supportive care and manage complications (e.g., biliary obstruction).
- See also “Principles of cancer care” for general information on treatment plans and goals of care.
Approximately 10–20% of patients present with resectable tumors, 30–40% present with borderline resectable disease, and 50–60% present with locally advanced or metastatic disease. 
|Treatment of pancreatic cancer by disease stage|
|Treatment intent||Resectability status ||AJCC stage||Typical treatment approach|
|Potentially curative||Resectable disease|| |
|Borderline resectable disease|| || |
|Usually palliative||Locally advanced unresectable disease|| |
|Palliative||Metastatic disease|| || |
The only potentially curative treatment for pancreatic cancer is surgical resection, usually in combination with other treatments. Neither chemotherapy nor radiation therapy can be curative without surgery.
Potentially curable disease 
- Primary surgical resection: recommended in patients with nonmetastatic disease who meet certain criteria.
- : for patients with features suggestive of prior to resectionmetastatic disease and/or less favorable performance status
Surgical resection 
See also “Pancreatic surgery.”
- Pancreatic head carcinoma: and lymphadenectomy
- Pancreatic body and tail carcinoma: : Typically involves resection of the left side of the pancreas with splenectomy
Chemotherapy and radiotherapy for potentially curable disease 
- Neoadjuvant therapy: to improve resectability
- Adjuvant therapy: to increase long-term survival
Following preoperative therapy, patients require full restaging to assess for resectability. 
Locally advanced and metastatic disease
Treatment intent is usually palliative. Patients with locally advanced disease may be able to undergo curative surgery if preoperative treatment leads to improved resectability; however, this is rare. 
- Locally advanced disease
- Metastatic disease
Supportive care 
Pain management 
- Radiotherapy: Consider for patients with symptomatic metastases, especially to the brain and bones (rare).
- Advanced interventions: Consider for patients with refractory abdominal pain. 
- Obtain nutrition counseling.
- Consider nutritional supplements and appetite stimulants (e.g., megestrol acetate, dronabinol).
- Treat pancreatic enzyme replacement. with
Monitoring and follow-up 
Data to guide monitoring for recurrence and follow-up recommendations after curative treatment for pancreatic cancer is limited. The following recommendations are based on expert opinion and consistent with the 2016 American Society of Clinical Oncology (ASCO) guidelines. 
Lymphogenic and hematogenous metastases are often already present at the time of diagnosis.
- Early stage: liver, nearby lymph nodes
- Advanced stage: surrounding visceral organs (duodenum, stomach, colon), lungs
Management of GI complications 
Biliary obstruction: e.g., stenosis of the common bile duct
- ERCP with stent implantation (preferred)
Percutaneous transhepatic bile duct drainage (PTCD)
- Involves placement of an external drain that drains the bile into a collection bag.
- Consider if endoscopic access is impaired.
- Surgical bypass: consider in select patients when other measures fail or are not feasible.
Gastric outlet and/or duodenal obstruction
- Preferred: endoscopic stent placement
- (or )
- Surgical bypass (e.g., )
- Malignant ascites
- Ileus: percutaneous endoscopic gastrostomy (PEG) tube as a relief tube
- Venous thromboembolism (VTE): See “Deep vein thrombosis” and “DVT prophylaxis” for details on prevention and management. 
- Disseminated intravascular coagulation (DIC)
- Secondary diabetes mellitus
We list the most important complications. The selection is not exhaustive.
Subtypes and variants
Pancreatic cystic lesions 
- Epithelium-lined cyst, filled with serous or mucous liquid
- Can be benign, precancerous, or cancerous
- Clinical features: usually asymptomatic
- Diagnosis: most often found incidentally on CT or MRI abdomen; can be followed by endoscopic investigations (e.g., , ) and tissue sampling (e.g., )
Management: varies depending on radiological and pathological features (e.g., size, location, degree of cell dysplasia) and patient characteristics (e.g., symptoms, ) 
- Offer surgical resection to patients with:
- Consider conservative management for asymptomatic individuals with low-risk lesions, e.g.:
Pancreatic cysts are common in patients with . 
Benign lesions 
Benign lesions have low malignancy potential and are typically .
- Serous cystadenomas: typically appears as a honeycomb-like cluster of cystic lesions 
- Simple cysts (retention cysts): typically appear as a single well-defined, nonenhancing, unilocular cyst without mural nodularity or calcification 
Precancerous lesions 
Surgical resection is usually offered to good surgical candidates; conservative management can be considered in select cases.
- Intraductal papillary mucinous neoplasms (IPMNs): most common pancreatic cystic neoplasm; malignancy potential 20–80% 
- Mucinous cyst neoplasm: most commonly affects women; malignancy potential up to 25% 
- Solid pseudopapillary neoplasms: most commonly affects young women; malignancy potential 10–15% 
- pancreas (e.g., islet cells) that can secrete a variety of hormones arising from endocrine cells in the
- Functional PNETs: secrete hormones; symptoms depend on the type of hormone secreted (e.g., insulinomas cause hypoglycemia)
- Nonfunctional PNETs: do not secrete enough hormones to cause symptoms; can produce local mass effect if large enough
- Malignancy potential varies widely.
Screening of asymptomatic individuals 
- Not recommended for average-risk individuals
- Consider periodic MRI and EUS for high-risk individuals, e.g.: