Pancreatic Cancer

Snapshot

A 69-year-old man presents to the emergency department with generalized fatigue and abdominal pain. He has had a 20-pound weight loss over the course of 3 months. He has a past medical history of alcohol use disorder and longstanding diabetes. He also has been smoking 1 pack of cigarettes for the past 50 years. Physical examination is notable for scleral icterus and abdominal tenderness to palpation in the epigastric region. CT abdomen with and without contrast demonstrates a mass at the head of the pancreas.

Introduction

Overview
- malignancy affecting the pancreas
- types
  - adenocarcinoma
    - > 90% of pancreatic cancers are adenocarcinoma
    - arising from the pancreatic ducts
    - most tumors arise in the head of the pancreas (~75%)
  - neuroendocrine
Epidemiology
- incidence
  - 4th leading cause of cancer in the United States
- demographics
  - > 60 years of age
- risk factors
  - smoking
  - heavy alcohol consumption
  - obesity
  - chronic pancreatitis
  - long standing diabetes
Etiology
- likely from accumulation of various genetic mutations
  - e.g., KRAS2 and CDKN2A
Pathogenesis
- pancreatic adenocarcinoma begins in the pancreatic ductal epithelium
  - premalignant lesions (e.g., pancreatic intraepithelial neoplasia) then progress to malignant lesions secondary to accumulation of genetic mutations
Prognosis
very poor prognosis

Presentation

Imaging

Abdominal ultrasound
- indication
  - initial imaging study in patients who present with jaundice
    - has a high sensitivity (> 95%) in detecting a pancreatic mass
Abdominal CT scan
- indication
  - initial imaging study in patients who present with abdominal pain and weight loss but without jaundice
  - confirms the presence of a pancreatic mass if it is found in the abdominal ultrasound
Endoscopic retrograde cholangiopancreatography (ERCP)
- indication
  - performed if abdominal ultrasound and abdominal CT scan do not demonstrate an obvious cause of biliary obstruction
    - can obtain a tissue diagnosis for small tumors that cannot be appreciated on the above imaging modalities
Endoscopic ultrasonography
- indication
  - can be used to obtain a tissue diagnosis
not always necessary if a resectable mass is demonstrated on abdominal CT scan

Studies

Serum labs
- CA 19-9
  - a tumor marker
- lipase
- AST, ALT, and alkaline phosphatase
may be elevated if the malignancy compresses the biliary system

Differential

Treatment

Complications