Pancreatic Cancer

 

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Original Editors - Jaimin Shah from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Pancreatic cancer is a malignant disease of the pancreas. “Pancreatic adenocarcinoma is a highly lethal disease, which is usually diagnosed in an advanced state” (Chenwei) The malignant tumor can be located near the head, body, or the tail of the pancreas. The pancreas is an organ that helps secrete insulin and glucagon which helps control blood glucose levels in the body. Pancreatic cancer is the fourth common cancer among men and the fifth leading cause of cancer in women. There are two types of pancreatic cancers which are exocrine cancer and endocrine cancer. “Pancreatic ductal adenocarcinoma (PDAC) compromises 90 % of pancreatic cancers.” ( Susannah shore) Exocrine pancreatic cancers are the most common of pancreatic cancers. Exocrine pancreatic cancer is involved in the ducts of the pancreas that secrete juices.

Prevalence

“It is estimated 43,140 men and women will be diagnose with pancreatic cancer and 36,800 men and women will die from pancreatic cancer in 2010”
“Pancreatic cancer is the fourth most common cause of cancer death for men and women in US” (Jeffrey farma) ; about 32,000 people die each year. Pancreatic cancer has the lowest 5-year survival rate (3 to 5 %). Pancreatic cancer is more common in black men and women than whites. “In the United States, the age-adjusted incidence of pancreatic cancer is higher in blacks (14.9 cases per 100,000) than in whites (11.1 cases per 100,000) and it is higher in men (12.8 cases per 100,000) than in women (10.0 cases per 100,000).” (Anirban Maitra) The peak incidence of pancreatic cancer occurs in the 7th and 8th decade.
Pancreatic cancer is rare in people under the age of 45, the risk increases after age of 50. The risk factors associated with pancreatic cancer include family history, genetic syndromes, tobacco use, exposure to chemicals, obesity, diets in high fats and meat, diabetes mellitus, hx of chronic pancreatitis, and hx of partial gastrectomy. “Individuals with a strong family history of pancreatic cancer have a significantly increased risk of developing the disease themselves.” (Anirban Maitra)

“The lifetime risk for developing pancreatic cancer for men and women is 1.27%. 1 in 80 men and women will develop cancer in their lifetime.” (Suresh Chari)

Characteristics/Clinical Presentation

Most clinical presentations of pancreatic cancers are vague and delay the potential diagnosis. “Pancreatic cancer is relatively asymptomatic during its early course. The vague presentation includes back and epigastric pain.” (Susannah shore) Symptoms associated with pancreatic cancer include:
Pain

Jaundice

Digestive Problems

Blood Clots
Weight Loss

Abdominal or Back Pain

Gallbladder Enlargement

Dark Urine
Nausea and Vomiting

Abdominal pain is more common among patients with pancreatic cancer. The pain is insidious in onset originating in the epigastric region moving towards the sides and back. (Susannah shore) “Pain is the presenting symptom in between 31% and 71% of pancreatic cancer patients” (Susannah shore)

Jaundice occurs from compression of the biliary duct. “About 70% of PDACs occur in the head of the pancreas” (Susannah shore) Therefor, patients are more likely to have this as symptomatic manifestation.

Advanced Cancer symptoms:
Weakness or very feeling tired
Loss of appetite or fullness

Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values

Spiral CT displays continuous images of the body. “Dual contrast enhanced spiral CT provides a continuous enhanced spiral CT that may provide diagnostic rates up to 97% for pancreatic cancer. CT scans can also help determine if a tumor is resectable. The sensitivity for determining resectability with a CT scan is in the range of 68% to 96% (Susannah Shore). The sensitivity drops to 58% when examining tumors less than 2 cm (Susannah shore). “Spiral CT with intravenous contrast of the abdomen is the most common test in the assessment of pancreatic adenocarcinoma.” (Goodman)

Carbon antigen 19-9 is detected in serum and pancreatic juice. “Carbon antigen 19-9 has a reported sensitivity of 70-90%, a specificity of 90%, PPV of 69%, NPV of 90%.” (Susannah shore) Carbon antigen 19-9 is produced normal in the body by the pancreas. An elevation of this serum can be indicated for other pancreatic disorders. CA 19-9 is not a useful screening tool for pancreatic cancer in asymptomatic population (Susannah shore).

TNM staging system classifies pancreatic adenocarcinoma into tumor size, local invasion, regional lymph node metastases, and distant nonnodal metastatic disease.

MRI is equal in comparison to CT scan for being sensitive in detecting pancreatic cancers. “With improved MRI with T1 and T2 imaging and with fast scanning techniques, tumor detection rate is reported up to 90%."

Transabdominal Ultrasound is used for investigating abdominal pain. “The sensitivity of transabdominal US in diagnosing pancreatic cancer has a wide range between 44% and 94%. Transabdominal US is poor in detecting small lesions of less than 1cm, with a sensitivity of 50%.” (Susannah shore)

Endoscopic Ultrasound is useful in detecting early pancreatic cancer as small as 2-3cm (Susannah shore). “A more recent report of series of 89 patients where EUS was compared with surgical and histopathological TNM staging found the overall accuracy to be 69% and 54% for tumor and nodal status.” (Susannah shore)

Endoscopic retrograde cholangiopancreatography (ERCP) is used for imaging of the pancreatic duct and biliary system. “The sensitivity and specificity of ERCP is 70-82% and 88-94% in symptomatic patients or those with suspected pancreatic cancer.” (Susannah shore)

Etiology/Causes

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Systemic Involvement

Pancreatic cancers are often diagnosed in advanced stages where the cancer has metastasized to other areas. Pancreatic cancers can metastasize to regional lymph nodes, liver, lungs, duodenum, stomach, colon, and anywhere in the abdominal cavity. Pancreatic cancer can spread to the skin as painful nodules. Usual sites for metastases in pancreatic cancer occur in the liver and peritoneal cavity (Mitesh Borad). 

Medical Management (current best evidence)

Treatment of pancreatic cancer is based on the stage of the tumor (Goodman).
Resectable Disease- 15-20%
Locally advanced- 40-45%
Metastatic- 40-45%

Surgery is the primary option if the pancreatic cancer is resectable. “Surgical resection provides the only curative therapy, only appropriate for a minority of clients.”(Goodman) “Around 9-15% of patients are suitable for potentially curative resection.” (Susannah Shore)
Kausch-Whipples (Pancreaticoduodenectomy) - This procedure involves the removal of the head of the pancreas, a portion of the small intestine, gallbladder, bile duct, and stomach. “Pancreaticoduodenectomy has been shown to have an overall mortality rate of 6.6%.” (Richard A Erickson) Some forms of morbidity with this operation include gastric emptying, pancreatic anastomotic leak, and postoperative abcessess (Richard Erickson).

Pylorus preserving pancreaticoduodenectomy (PPPD)- This procedure is similar to the Kausch-Whipples except it spares the pylorus. This modification is sometimes included to increase nutritional strength in patients who will potentially have gastric emptying which leads to nutritional deficiencies (Richard Erickson). “The preservation of the pyloric sphincter should decrease morbidity and prevent biliary reflux and retention of the duodenal pacemaker should reduce delayed gastric emptying.” (Susannah Shore)

Left pancreatectomy- This procedure involves the removal of the tail of the pancreas.

Chemotherapy-

Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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