Definition
A.Adenocarcinoma of the pancreas (referred to as pancreatic cancer) originates from the exocrine cells of the pancreas.
B.Pancreatic cancer comprises more than 95% of pancreatic malignancies.
Incidence
A.Pancreatic cancer is the fourth leading cause of cancer deaths in the United States with an estimated 53,070 new cases and 41,780 deaths from pancreatic cancer in 2016.
B.The overall risk of developing pancreatic cancer increases after 50 years of age and the majority of patients with disease are between the ages of 60 and 80 years.
C.The only potentially curative therapy for pancreatic cancer is surgical resection of the involved portion of the pancreas in patients with localized disease. Unfortunately, 80% of patients have metastatic and locally advanced disease at initial diagnosis, which precludes curative resection for the majority of patients.
D.In patients who have undergone resection with curative intent, only 10% to 27% of patients survive at least 5 years after surgical resection. Meanwhile, the 5-year overall survival rate for all pancreatic cancer stages combined remains low at 8%.
Pathogenesis
A.Pancreatic cancer is caused by mutations to DNA.
B.Insults to DNA can be hereditary or environmental such as alcohol, smoking, drugs, and obesity.
C.Acute pancreatitis and recurrent acute pancreatitis can develop into chronic pancreatitis, which can convert to pancreatic cancer.
D.Most cases of pancreatic cancer are adenocarcinomas.
Predisposing Factors
A.Cigarette smoking.
B.Alcoholism.
C.Obesity.
D.Chronic pancreatitis.
E.Diabetes mellitus.
F.Family history.
G.Genetic mutations.
Subjective Data
A.Common complaints/symptoms.
1.Pain.
2.Jaundice.
3.Weight loss.
4.Steatorrhea.
5.Nausea.
6.Hyperglycemia.
7.Diabetes mellitus.
B.Common/typical scenario.
1.The pancreas is located proximal to the stomach, small intestine, and bile duct so clinical manifestations of pancreatic cancer usually affect the anatomy and function of these adjacent structures. For example:
a.A pancreatic tumor obstructing the biliary system could cause jaundice.
b.Nausea, digestive problems, and weight loss may result from obstruction of the upper digestive tract.
c.Steatorrhea can result from an obstruction of the pancreatic duct that prevents the passage of digestive enzymes into the intestines.
Physical Examination
A.Head and neck: Inspect for scleral icterus and palpate for cervical and supraclavicular lymphadenopathy.
B.Integumentary: Inspect for jaundice.
C.Abdomen: Inspect and palpate for mass effect, ascites, hepatosplenomegaly, and pain.
D.Weight assessment: Measure weight at each visit especially when nutritionally compromised.
E.Complete a full examination including cardiopulmonary, musculoskeletal, and neurology assessment to evaluate the patient’s overall fitness for oncology treatment.
Diagnostic Tests
A.Laboratory data.
1.Complete blood count (CBC).
2.Comprehensive metabolic panel (CMP).
3.Prealbumin for nutrition status assessment.
4.CA 19–9.
B.Diagnostic imaging.
1.Multiphase helical CT scan.
a.A CT scan with contrast can correctly predict resectability in pancreatic cancer with 80% to 90% accuracy.
2.Endoscopic evaluation.
a.Esophagogastroduodenoscopy (EGD).
b.Endoscopic retrograde cholangiopancreatography (ERCP).
C.Staging: The American Joint Committee on Cancer (AJCC) has developed a staging system based on tumor, node, metastasis (TNM) status for pancreatic cancer.
Differential Diagnosis
A.Acute pancreatitis.
B.Cholangitis.
C.Cholecystitis.
D.Gastric cancer.
E.Peptic ulcer disease.
Evaluation and Management Plan
A.General plan.
1.Chemotherapy, radiation, and surgery are utilized in the treatment of pancreatic cancer.
2.The modalities employed and the sequence in which they are administered often depend on the clinical stage of disease.
3.Neoadjuvant therapy for pancreatic cancer refers to chemotherapy and/or radiation administered prior to surgery.
4.Surgery.
a.The majority of pancreatic cancers arise from the pancreatic head and these lesions, if resectable, are treated with a pancreaticoduodenectomy, commonly known as the Whipple procedure.
b.Resectable pancreatic tail cancers are treated with a distal pancreatectomy which can also involve a splenectomy depending on the splenic vessel involvement of the tumor.
5.Chemotherapy.
6.Radiation.
Follow-Up
A.Routine follow-up is essential.
B.Patients should have CT imaging at 3- to 6-month intervals for the first 2 years and then annually.
Consultation/Referral
A.Consults should be made to gastroenterology, medical oncology, radiation oncology, and general surgery.
Special/Geriatric Considerations
A.Prognosis for pancreatic cancer is very poor and largely incurable.
B.The 5-year relative survival rate is 7% for all stages of pancreatic cancer.
Bibliography
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Fernandez-del Castillo, C. (2019, January 18). Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer. In D. M. F. Savarese & K. M. Robson (Eds.), UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-staging-of-exocrine-pancreatic-cancer
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National Cancer Institute. (2016, September 12). Surveillance, epidemiology, and end results program. Retrieved from https://seer.cancer.gov/faststats/selections.php?series=cancer