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Pancreatic cancer
Written by Jeffrey R. Waggoner, MD   

Both the exocrine and endocrine portions of the pancreas can engender cancer. 95% of pancreatic cancers come from its exocrine portion. The head or neck is responsible for 75% of cancers, 15% to 20% from the body, and 5% to 10% from the tail. The most common sites of initial metastasis are regional lymph nodes. The next most common sites are liver and lungs. Pancreatic carcinoma can also spread by direct extension into the duodenum, stomach, and colon. Although heavily studied, the genetic basis for Pancreatic cancer is as yet not of clinical relevance.     

Possible causative agents

It appears that chronic inflammation, specifically the abuse of alcohol and tobacco is the most important causative agent for Pancreatic cancer. Chronic pancreatitis, regardless of cause, is also associated with an increased incidence. (1)

Clinical presentation

Because the pancreas rests in a very posterior position, it is difficult to detect on examination. Thus, Pancreatic cancer is usually detected late in its course, after it has spread to adjacent viscera or after it has metastasized.     

One exception to this is ampullary cancer. This is because this cancer, located at the junction of the bile duct to the duodenum, often causes jaundice early in its course.

Typically, patients will present with abdominal pain, nausea, loss of appetite, unexplained weight loss, and jaundice. Later on, the symptoms may include chronic, severe pain, nausea, vomiting, malabsorption, and insulin insufficiency. The general nature of these complaints will often delay a correct diagnosis.

Diagnosis

Imaging techniques utilized in diagnosis include computed tomography (CT), transabdominal ultrasound, and MRI. Endoscopic retrograde cholangiopancreatography (ERCP) utilizes an endoscope to reach the pancreas and may define its anatomy with adjunctive dye injection. This technique may be combined with MRI in a procedure known as magnetic resonance cholangiopancreatography (MRCP). Biopsy and tissue histology are obviously the end goal of all diagnostic workups.

Lab tests typically utilized in a workup include comprehensive profiles as part of a general workup for jaundice; CA 19-9, a tumor marker for Pancreatic cancer, helpful in monitoring the disease but not in screening; CEA, another tumor marker; and trypsin, trypsinogen, amylase, and lipase to monitor pancreatic function.

Treatment options

Treatment for Pancreatic cancer usually combines surgery—based upon the diseases staging—and chemotherapy. No treatment regimen is highly successful and five year survival data is very low. However, new combinations of drugs are being used and new drugs are being introduced on an ongoing basis. (2)

 
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