Pancreatic cancer is the sixth most common cause of cancer-related death in Europe.
Most common presentation is at 65 to 75 years of age with painless obstructive jaundice and weight loss. Generally presents late with advanced disease.
Surgical resection offers the only hope for cure. Chemotherapy and radiotherapy, as primary treatment modalities, produce a small but statistically significant benefit. Adjuvant chemotherapy prolongs survival.
Only a minority (5% to 10%) of patients can undergo potentially curative surgery: these patients have a 5-year survival of up to 22%, which decreases to <2% in the presence of distant metastasis.
Patients with metastatic disease (50% to 55%) have a limited survival of only 3 to 6 months.
Chemotherapy or immunotherapy may provide some benefit for selected patients.
'Pancreatic cancer' refers to primary pancreatic ductal adenocarcinoma, which accounts for >90% of all pancreatic neoplasms. The course of pancreatic cancer has been shown to follow a linear progression model from pre-invasive pancreatic intraepithelial neoplastic lesions to invasive ductal adenocarcinoma. Two additional well-defined precursor lesions are the intraductal papillary mucinous neoplasm and the mucinous cystic neoplasm.
For diagnosis and management of neuroendocrine tumours of the pancreas, see the BMJ Best Practice topic VIPoma.
History and exam
Key diagnostic factors
- presence of risk factors
- non-specific upper abdominal pain or discomfort
- weight loss and anorexia
- back pain
Other diagnostic factors
- age 65 to 75 years
- thirst, polyuria, nocturia, and weight loss
- nausea, vomiting, and early satiety
- unexplained acute pancreatitis
- epigastric abdominal mass
- positive Courvoisier's sign
- petechiae, purpura, bruising
- Trousseau's sign (migratory thrombophlebitis)
- family history of pancreatic cancer
- other hereditary cancer syndromes
- chronic sporadic pancreatitis
- diabetes mellitus
- dietary factors
1st investigations to order
- pancreatic protocol CT
- abdominal ultrasound
Investigations to consider
- prothrombin time (PT)
- cancer antigen (CA)19-9 biomarker
- positron emission tomography
- endoscopic retrograde cholangiopancreatography (ERCP)
- magnetic resonance cholangiopancreatography
- endoscopic ultrasound
- staging laparoscopy (with laparoscopic ultrasound)
- genomic testing
resectable (stages I and II)
locally advanced unresectable (stage III)
metastatic (stage IV)
Hemant M. Kocher, MBBS, MS, MD, FRCS
Professor of Liver and Pancreas Surgery
Barts Cancer Institute
Barts and The London School of Medicine and Dentistry
HMK is an author of a number of references cited in this topic. HMK has received trial funding from Celgene, advisory board honorarium from Baxalta Inc., and educational grants from Mylan, Celgene, Ethicon, and Medtronic.
Dr Hemant M. Kocher wishes to gratefully acknowledge Dr Fieke E.M. Froeling, a previous contributor to this topic.
FEMF is an author of a reference cited in this topic.
Ross Carter, FRCS
Consultant Pancreatic Surgeon
West of Scotland Pancreatic Unit
Glasgow Royal Infirmary
Nikhil I. Khushalani, MD
Assistant Professor of Oncology
Roswell Park Cancer Institute
NIK has received funding for the conduction of clinical trials and associated translational studies from Merck, Pfizer, and Astra-Zeneca. NIK has a grant from the National Comprehensive Cancer Network (from research support by Roche).
- Chronic pancreatitis
- Bile duct stones
- Ampullary carcinoma
- Adverse events associated with EUS and EUS-guided procedures
- Informed consent for GI endoscopic procedures
Pancreas cancer: questions to ask your doctorMore Patient leaflets
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