Carcinoma of the pancreas should be suspected in a patient with
continuous upper abdominal discomfort or notable unexplained weight loss
painless jaundice.
The possibility of carcinoma of the pancreas should also be kept in mind in patients with upper abdominal pain, recent-onset diabetes or acute pancreatitis.
Epidemiology
Pancreatic ductal adenocarcinoma (PDAC) is among the ten most common cancers.
Endocrine tumours of the pancreatic isles (insulinoma, gastrinoma, vipoma, glucagonoma, somatostatinoma, carcinoid tumour) are very rare.
Symptoms and occurrence
Weight loss 90%
Vague upper abdominal discomfort 80%
Jaundice 55%
Epigastric pain radiating to the back 30%
Recent-onset diabetes 30%
Loss of appetite 20%
Malaise 15%
Symptoms caused by endocrine activity of the tumour
Diagnostics
Routine laboratory examinations are not helpful in early diagnosis. Plasma alkaline phosphatase and glutamyl transferase concentrations are often increased.
The sensitivity and specificity of CA 19-9 is about 80%. It is mainly used in specialized care for the diagnosis and monitoring of carcinoma of the pancreas.
Ultrasonography may show a biliary obstruction or liver metastases and sometimes a tumour in the pancreas. A normal ultrasonographic finding does not exclude carcinoma of the pancreas, because the visibility of the pancreas is almost always incomplete and there may be no bile duct obstruction.
In the case of suspected carcinoma of the pancreas, the basic examination is a contrast-enhanced body CT scan, which is performed in specialized care as a multiphasic, targeted examination of the pancreas.
In unclear situations, further investigations may include upper abdominal MRI, ultrasonography-guided sampling either endoscopically or percutaneously, or PET-CT.
Treatment
Pancreaticoduodenectomy (Whipple's procedure) can be performed if the tumour has not spread to adjacent tissues. It is possible in approximately 20% of patients.
Chemotherapy and/radiotherapy for tumours that have spread to adjacent tissues provide palliative relief to about 50% of the patients but improve long-term prognosis only slightly.
Results of chemotherapy are poor.
Palliative surgical bypass of the biliary or digestive tract to relieve symptoms of obstruction may be performed if necessary.
Prognosis
Centralization of surgical treatment improves outcomes and long-term prognosis.
The 5-year age- and gender-adjusted survival rate for PDAC is below 10%. If surgical treatment is feasible, the prognosis is significantly better (up to over 20-25%).
More than half of patients diagnosed with ductal adenocarcinoma of the pancreas die within 6 months from diagnosis. On the other hand, 1 in 8 patients treated with radical surgery survives for more than 10 years.
The prognosis of periampullar carcinoma is better (because diagnosis is made earlier).