Pancreatic cancer is the third most common cause of cancer-related death in the US.
Most common presentation is at 65-75 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 radiation therapy, 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 3-6 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 preinvasive 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 tumors of the pancreas, see VIPoma.
History and exam
Key diagnostic factors
- nonspecific upper abdominal pain or discomfort
- weight loss and anorexia
- back pain
Other diagnostic factors
- age 65-75 years
- thirst, polyuria, nocturia, and weight loss
- nausea, vomiting, and early satiety
- unexplained acute pancreatitis
- epigastric abdominal mass
- positive Courvoisier sign
- petechiae, purpura, bruising
- Trousseau 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)
- MRI abdomen
- magnetic resonance cholangiopancreatography
- endoscopic ultrasound
- staging laparoscopy (with laparoscopic ultrasound)
- genomic testing
resectable (stages 1 and 2)
locally advanced unresectable (stage 3)
metastatic (stage 4)
- Chronic pancreatitis
- Bile duct stones
- Ampullary carcinoma
- NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma
- Management of toxicities from immunotherapy: ESMO clinical practice guideline for diagnosis, treatment and follow-up
Pancreas cancer: questions to ask your doctorMore Patient leaflets
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