Adenocarcinoma of the Pancreas

Ductal adenocarcinoma arising in the exocrine part of pancreas,

account for 80-90% of pancreatic tumor. Cystadenocarcinoma and
endocrine tumour account for most of the remains of malignancy.
About two-thirds of pancreatic adenocarcinomas arise within the head
or uncinate process of the pancreas; 15% are in the body, and 10% in
the tail, with the remaining tumors demonstrating diffuse involvement
of the gland. The prevalence of the head in the surgical series result
from earlier detection and better resectability. The average size of
tumors of the head is about 2-3 cm and is smaller than tose of the
body and tail, about 5-7 cm (Gourtsoyiannis, 2005). Despite its
ubiquity, this disease is extremely difficult to treat, and its exact cause
is unknown. However, epidemiologic studies linking various
environmental and host factors provide some clues. The etiology of
pancreatic cancer likely involves a complex interaction of genetic and
environmental factors (Brunicardi, 2014).
Pancreatic cancer is more common in the elderly with most
patients being >60 years old. Peak incidence is in the 6th and 7th
decade. Pancreatic cancer is more common in men than women. The
risk of developing pancreatic cancer is two to three times higher if a
parent or sibling had the disease. Smoking increases the risk of
developing pancreatic cancer by at least twofold due to the
carcinogens in cigarette smoke. As in other GI cancers, diets high in fat
and low in fiber, fruits, and vegetables are thought to be associated
with an increased risk of pancreatic cancer. Diabetes has been known
to be associated with pancreatic cancer for many years. In fact,
glucose intolerance is present in 80% of patients with pancreatic
cancer, and approximately 50% have overt diabetes. Pre-existing type
2 diabetes increases the risk for development of pancreatic cancer by
about twofold. (Brunicardi, 2014).
Although exact pathophysiologic mechanism is unknown,
pancreatic cancer is related to mutation of K-ras oncogene in 90% of
pancreatic tumours. It s detected in DNA from serum, stool, pancreatic
juice, tissue aspirates. Another is overexpression of HER-2/neu
oncogene which is exaggeration of cellular proliferation. 10% of
pancreatic cancers: result of inherited genetic predisposition as
manifested by family history of pancreatic cancer increases the risk by
two-fold (Brunicardi, 2014).
Pancreatic cancer probably arises through a step-wise
progression of cellular changes, just as colon cancer progresses by
stages from hyperplastic polyp to invasive cancer. Systematic
histologic evaluation of areas surrounding pancreatic cancers has

revealed the presence of precursor lesions that have been named

pancreatic intraepithelial neoplasia.
Spread of pancreatic tumours is by local Invasion, lymphatic,
blood and via peritoneal & omental causing ascites. The diagnosis of
pancreatic cancer varies from the simple and clinically obvious to the
most difficult and almost impossible the initial symptoms and signs
depend on the site and extent of the pancreatic cancer.
Clinical manifestation includes weight loss, icteric skin, distented
gallbladder in 1/4 of patients, pain perceived in epigastrium,
experienced as mild and vague, jaundice, the most common and may
present as painless, steatorrhea, duodenal obstruction, a late event
and present in about 20% of patients, diabetes mellitus, acute
pancreatitis, malignant ascites, gastric outlet obstruction.
Approach to investigations include ultrasound scan especially for
patients with jaundice, CT scan, MRI scan, PET scan, ERCP, histology
and cytology, angiography of the celiac and superior mesenteric artery
and laparoscopy. CT Scan is the single most versatile and cost-effective
tool for diagnosis and staging of pancreatic cancer. It is done for
patients who present pain but with no jaundice. Accuracy of 90-95% in
unresectable diseases it is less accurate in resectable diseases. PET
Scan is used to distinguish chronic pancreatitis from pancreatic cancer.
The American Joint Committee on Cancer proposed TNM Staging
for Pancreatic Cancer as shown by the table below.

Over 90% of patient with pancreatic cancer present in the late

stage of their disease. At this time, there is no chance of cure. Only
palliation is an effective form of management. The factors responsible
for late diagnosis are tumor is asymptomatic in the early stage, patient
delay, physician delay and the patient may not have ready and easy
access to competent diagnostic center.

Refrence:
Brunicardi, F. (2014). Schwartz's principles of surgery (8th ed.). New
York: McGraw-Hill, Health Pub. Division.
Gourtsoyiannis, N. (2005). Radiologic-pathologic correlations from head
to toe: Understanding the manifestations of disease. Berlin: Springer.