Gastroenterology Book

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Pancreatic CancerAka: Pancreatic Adenocarcinoma, Courvoisier's Sign

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  1. Epidemiology
    1. Incidence: 2% of new cancers in United States
    2. Fourth leading cause of cancer deaths in United States
  2. Risk Factors
    1. Family History of certain familial cancer syndromes
    2. Increasing age (starting at 50 years old)
    3. Tobacco Abuse
    4. Obesity
    5. Diabetes Mellitus
    6. Other possible risks: Alcohol, Caffeine
  3. Pathophysiology
    1. Adenocarcinoma of pancreatic ductal epithelium
    2. Onset usually in head of pancreas
  4. Symptoms
    1. Unexplained weight loss (>5 pounds per month)
    2. Biliary duct blockage (if head of pancreas involved)
      1. Jaundice
      2. Dark urine and light colored stool
    3. Epigastric Abdominal Pain radiating to back
    4. Nausea or Vomiting
    5. Anorexia
    6. Weakness
  5. Signs
    1. Non-specific findings
      1. Cachectic patient
      2. Bruising
      3. Jaundice (if biliary duct obstruction)
    2. Courvoisier's Sign
      1. Non-tender, but distended, palpable gall bladder
      2. Associated with Jaundice
      3. Test Sensitivity <56%, but Specificity >82%
    3. Other findings
      1. Lymphadenopathy involving Virchow's Node
  6. Labs
    1. General markers (if biliary duct obstruction)
      1. Alkaline Phosphatase increased
      2. Conjugated Serum Bilirubin increased
    2. Tumor Markers
      1. CA 19-9 (use for diagnosis/prognosis, NOT screening)
      2. bHCG (better prognostic indicator then CA 19-9)
      3. CA 72-4 (better prognostic indicator then CA 19-9)
  7. Diagnostics
    1. Routine screening not recommended in general
      1. Consider endoscopic ultrasound if Family History
    2. Initial testing
      1. Standard CT Abdomen
      2. Transabdominal ultrasound
    3. Most accurate testing
      1. Dual-phase helical CT (preferred)
      2. Endoscopic ultrasound
        1. Indicated if helical CT not diagnostic
        2. Guides FNA in non-operable cancer
    4. Other testing
      1. MRI is not recommended (less sensitive than CT)
      2. ERCP no longer used for pancreatic cancer diagnosis
  8. Staging
    1. Protocol
      1. Dual-phase helical CT abdomen and pelvis (first line)
      2. If diagnosis uncertain
        1. Fine needle aspirate
        2. Endoscopic ultrasound
    2. Stages
      1. Resectable (15% five year survival)
        1. Accounts for 15-20% of pancreatic cancer
        2. Body or tail cancer more advanced at presentation
          1. Less commonly resectable at presentation
      2. Locally advanced (6.3% five year survival)
      3. Metastatic (1.6% five year survival)
  9. Management: General
    1. See Cachexia in Cancer
    2. See Mood Disorders in Cancer
    3. Treat Cancer Pain
      1. See Cancer Pain Management
      2. Celiac plexus neurolysis (via endoscopic ultrasound)
        1. Alcohol injected into celiac plexus
        2. Significantly reduces pain
    4. Pancreatic Cancer specific concerns
      1. Malabsorption from exocrine pancreatic insufficiency
      2. Pancrealipase 30,000 IU
        1. Taken before, during and after meal
      3. Jaundice secondary to biliary obstruction
        1. Biliary decompression via surgery or endoscopy
  10. Management: Resectable pancreatic cancer
    1. Criteria for resectable cancer
      1. No distant metastatic cancer
      2. No vascular invasion
        1. No superior mesenteric artery involvement
        2. No aorta or inferior vena cava involvement
        3. No celiac involvement
    2. Surgery
      1. Cancer involving head of pancreas
        1. Whipple Procedure or
        2. Pylorus-Preserving Pancreaticoduodenostomy
      2. Cancer involing body and tail of pancreas
        1. Distal pancreatectomy
    3. Adjuvant Chemotherapy
      1. Leucovorin and fluorouracil apper to be effective
      2. Radiation associated with worse prognosis
  11. Management: Locally advance pancreatic cancer
    1. Combination protocol: Chemoradiotherapy
      1. Radiation Therapy and
      2. Fluorouracil
    2. Efficacy
      1. One year survival: 40% (versus 10% with no treatment)
  12. Management: Metastatic pancreatic cancer
    1. Consider Gemcitabine (improves 1 year survival)
    2. Palliative Care - involve Hospice early
  13. Prevention
    1. Fruit and vegetables in diet
    2. Exercise
    3. NSAIDs (possible)
  14. Prognosis
    1. At diagnosis, only 15-20% of cancers are localized
  15. References
    1. Freelove (2006) Am Fam Physician 73(3):485
    2. Li (2004) Lancet 363:1049

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