Final Diagnosis

Pancreatic

Cancer

Pancreatic cancer

• It is a malignant neoplasm of the pancreas.

• The prognosis is generally poor; less than 5 percent of those diagnosed are still alive five years after diagnosis.

• Complete remission is still extremely rare.

Pancreatic cancer

• Most of the cancers that arise in the pancreas start off from the lining of the ducts, and are called ductal adenocarcinoma.

• Interestingly 80-90% of these are in the head of the gland.

Pancreatic cancer

• About 95% of exocrine pancreatic cancers are adenocarcinomas (M8140/3).

• The remaining 5% include adenosquamous carcinomas, signet ring cell carcinomas, hepatoid carcinomas, colloid carcinomas, undifferentiated carcinomas, and undifferentiated carcinomas with osteoclast-like giant cells.

• Exocrine pancreatic cancers are far more common than endocrine pancreatic cancers (also known as islet cell carcinomas), which make up about 1% of total cases.

Pancreatic cancer

• Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms, and the later symptoms are usually non-specific and varied. Therefore, pancreatic cancer is often not diagnosed until it is advanced. Common symptoms include:

• Pain in the upper abdomen that typically radiates to the back (seen in carcinoma of the body or tail of the pancreas)

• Loss of appetite and/or nausea and vomiting

• Significant weight loss

Pancreatic cancer• Painless jaundice (yellow

skin/eyes, dark urine) when a cancer of the head of the pancreas (about 60% of cases) obstructs the common bile duct as it runs through the pancreas. This may also cause pale-colored stool and steatorrhea.

• Trousseau sign, in which blood clots form spontaneously in the portal blood vessels, the deep veins of the extremities, or the superficial veins anywhere on the body, is sometimes associated with pancreatic cancer.

Pancreatic cancer

• Diabetes mellitus, or elevated blood sugar levels. Many patients with pancreatic cancer develop diabetes months to even years before they are diagnosed pancreatic cancer, suggesting that new onset diabetes in an elderly individual may be an early warning sign of pancreatic cancer.

• Clinical depression has been reported in association with pancreatic cancer, sometimes presenting before the cancer is diagnosed. However, the mechanism for this association is not known.

Pancreatic cancerPredisposing factors• Risk factors for pancreatic cancer

include:• Age (particularly over 60) • Male gender • African-American ethnicity • Smoking. Cigarette smoking has a

risk ratio of 1.74 with regard to pancreatic cancer; a decade of non-smoking after heavy smoking is associated with a risk ratio of 1.2.

• Diets low in vegetables and fruits• Diets high in red meat• Obesity

Pancreatic cancer

• Diabetes mellitus is both risk factor for pancreatic cancer, and, as noted earlier, new onset diabetes can be an early sign of the disease.

• Chronic pancreatitis has been linked, but is not known to be causal. The risk of pancreatic cancer in individuals with pancreatitis is particularly high.

• Helicobacter pylori infection

Pancreatic cancer• Family history, 5–10% of pancreatic cancer patients have a family

history of pancreatic cancer. • The genes responsible for most of this clustering in families have

yet to be identified. Pancreatic cancer has been associated with the following syndromes; autosomal recessive ataxia-telangiectasia and autosomal dominantly inherited mutations in the BRCA2 gene and PALB2 gene, Peutz-Jeghers syndrome due to mutations in the STK11 tumor suppressor gene, hereditary non-polyposis colon cancer (Lynch syndrome), familial adenomatous polyposis, and the familial atypical multiple mole melanoma-pancreatic cancer syndrome (FAMMM-PC) due to mutations in the CDKN2A tumor suppressor gene.

• Gingivitis or periodontal disease

Alcohol

• It is controversial whether alcohol consumption is a risk factor for pancreatic cancer. Drinking alcohol excessively is a major cause of chronic pancreatitis, which in turn predisposes to pancreatic cancer, but "chronic pancreatitis that is due to alcohol doesn't increase risk as much as other types of chronic pancreatitis."[clarification needed .

• Overall, the association is consistently weak and the majority of studies have found no association.

• Some studies suggest a relationship, with risk increasing with increasing amount of alcohol intake.

• Risk is greatest in heavy drinkers mostly on the order of four or more drinks per day. But there appears to be no increased risk for people consuming up to 30g of alcohol a day,

• Several studies caution that their findings could be due to confounding factors. Even if a link exists, it "could be due to the contents of some alcoholic beverages" other than the alcohol itself. One Dutch study even found that drinkers of white wine had lower risk.

• A pooled analysis concluded, "Our findings are consistent with a modest increase in risk of pancreatic cancer with consumption of 30 or more grams of alcohol per day."

Diagnosisof Pancreatic CA

• Most patients with pancreatic cancer experience pain, weight loss, or jaundice.

• Pain is present in 80 to 85 percent of patients with locally advanced or advanced metastic disease.

• The pain is usually felt in the upper abdomen as a dull ache that radiates straight through to the back.

• It may be intermittent and made worse by eating. Weight loss can be profound; it can be associated with anorexia, early satiety, diarrhea, or steatorrhea.

Diagnosisof Pancreatic CA

• Jaundice is often accompanied by pruritus and dark urine. Painful jaundice is present in approximately one-half of patients with locally unresectable disease, while painless jaundice is present in approximately one-half of patients with a potentially resectable and curable lesion.

• The initial presentation varies according to location of the cancer.

• Malignancies in the pancreatic body or tail usually present with pain and weight loss, while those in the head of the gland typically present with steatorrhea, weight loss, and jaundice.

• The recent onset of atypical diabetes mellitus, a history of recent but unexplained thrombophlebitis (Trousseau sign), or a previous attack of pancreatitis are sometimes noted.

Diagnosisof Pancreatic CA

• Courvoisier sign defines the presence of jaundice and a painlessly distended gallbladder as strongly indicative of pancreatic cancer, and may be used to distinguish pancreatic cancer from gallstones.

• Tiredness, irritability and difficulty eating due to pain also exist. Pancreatic cancer is usually discovered during the course of the evaluation of aforementioned symptoms.

Liver Function Test• Liver function tests can show a combination

of results indicative of bile duct obstruction (raised conjugated bilirubin, γ-glutamyl transpeptidase and alkaline phosphatase levels).

• CA19-9 (carbohydrate antigen 19.9) is a tumor marker that is frequently elevated in pancreatic cancer. However, it lacks sensitivity and specificity. When a cutoff above 37 U/mL is used, this marker has a sensitivity of 77% and specificity of 87% in discerning benign from malignant disease.

• CA 19-9 might be normal early in the course, and could be elevated due to benign causes of biliary obstruction.

Imaging Studies• Endoscopic ultrasound (EUS)

is another procedure that can help visualize the location and can serve to guide a percutaneous needle biopsy, which is necessary to establish a definitive diagnosis.

• EUS has the highest accuracy in detecting small lesions, in assessing tumor size and lymph node involvement, but helical CT must still be the first choice in patients with a suspected pancreatic tumor.

Imaging Studies

• Imaging studies, such as computed tomography (CT scan) can be used to identify the location of the cancer.

• A CT scan of the upper abdomen showing a tumor (pancreas carcinoma) in the head of the pancreas, seen here in the middle of the picture.