PANCREATIC CANCER

 An estimated 29,200 patients will develop

pancreatic cancer in the United States in
2001, and 28,900 will die of the disease
 Factors associated with an increased risk of
pancreatic cancer are
 cigarette smoking, dietary consumption of
meat (especially fried meat) and fat,
previous gastrectomy (> 20 years earlier),
and race (in the USA but not Africa, blacks
are more susceptible than whites).
 The peak incidence is in the fifth and
sixth decades. In two-thirds of cases,
the tumor is located in the head of
the gland
 Pancreatic adenocarcinoma is
characterized by early local
extension to contiguous structures
and metastases to regional lymph
nodes and the liver.
 Symptoms and Signs
 Carcinoma of the Head of the Pancreas

 About 75% of patients with carcinoma of

the head of the pancreas present with
weight loss, obstructive jaundice, and
deep-seated abdominal pain.
 Back pain occurs in 25% of patients and
is associated with a worse prognosis.
 In general, smaller tumors confined
with less pain.
 Weight loss
 Hepatomegaly.
 A palpable mass, which is found in
20%, nearly always signifies surgical
incurability.
 Jaundice
 Cholangitis occurs in only 10% of
patients with bile duct obstruction.

 A palpable nontender gallbladder in a

jaundiced patient suggests neoplastic
obstruction of the common duct
(Courvoisier's sign), most often due to
pancreatic cancer; this finding is present
in about half of cases.
 Laboratory Findings
 Elevated alkaline phosphatase and bilirubin
levels The bilirubin level with neoplastic
obstruction averages 18 mg/dL, much higher
than that generally seen with benign disease of
the bile ducts.
 Serum levels of the tumor marker CA 19-9 are
elevated in most patients with pancreatic
cancer, but the sensitivity in resectable (< 4 cm)
lesions is probably too low (50%) for this to
serve as a screening tool.
 The greatest usefulness of CA 19-9
measurements may be in following the results
of treatments.
 Imaging Studies
 CT Scan
 ERCP
 Upper Gastrointestinal Series
 Other Studies
 Angiography has not proved reliable in
detecting or staging pancreatic neoplasms, and
ultrasound is a poor second to CT scans for
imaging.
 Aspiration Biopsy
 Differential Diagnosis
 The other periampullary neoplasms—
carcinoma of the ampulla of Vater, distal
common bile duct, or duodenum—may
also present with pain, weight loss,
obstructive jaundice, and a palpable
gallbladder. Preoperative
cholangiography and gastrointestinal x-
rays may suggest the correct diagnosis,
but laparotomy is sometimes required.
 Complications

 Obstructionof the splenic vein by

tumor may cause splenomegaly and
segmental portal hypertension with
bleeding gastric or esophageal
varices
 Treatment
 Pancreatic resection for pancreatic
cancer is appropriate only if all gross
tumor can be removed with a standard
resection. The lesion is considered
resectable if the following areas are free
of tumor: (1) the hepatic artery near the
origin of the gastroduodenal artery; (2)
the superior mesenteric artery where it
courses under the body of the pancreas;
and (3) the liver and regional lymph
nodes.
 For curable lesions of the head,
pancreaticoduodenectomy (Whipple
operation) is required
 This involves resection of the common bile
duct, the gallbladder, the duodenum, and the
pancreas to the mid body.
For unresectable lesions,
cholecystojejunostomy or
choledochojejunostomy
provides relief of jaundice and
pruritus
 Gemcitabine-based chemotherapy
has clear benefits in patients with
metastatic disease. Its utility in
combination with radiation therapy
and as adjuvant therapy is being
defined
 Prognosis

 The mean survival following

palliative therapy is 7 months.
Following a Whipple procedure,
survival averages about 18 months