Editors

PauliPuolakkainen

Carcinoma of the Pancreas

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.

Globally, there are over 510 000 cases of pancreatic cancer each year, and it causes nearly 470 000 deaths annually http://gco.iarc.who.int/media/globocan/factsheets/cancers/13-pancreas-fact-sheet.pdf. By incidence, it is the 12^th most common cancer, and it ranks 6^th in cancer-related mortality.
Pancreatic neuroendocrine tumours are rare; see Rare Endocrine Tumours.

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%
In hormonally functional neuroendocrine tumours, symptoms caused by hormone secretion

Routine laboratory examinations are not helpful in early diagnosis. Plasma alkaline phosphatase and bilirubin concentrations are often increased.
The sensitivity and specificity of CA 19-9 is about 80%. It is sometimes used as a starter of diagnostics and as guiding support in the detection of pancreatic cancer, as well as in association with follow-up in the detection of post-operative recidivation.
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.

Surgical treatment of pancreatic cancer takes place in tertiary care hospitals.
Based on the location of the tumour, either pancreaticoduodenectomy (Whipple's procedure) or resection of the pancreatic body and tail is performed if the tumour has not spread to adjacent tissues. It is possible in approximately 10-20% of patients.
Neoadjuvant therapy can increase the possibilities of surgical treatment.
Chemotherapy and/radiotherapy for tumours that have spread to adjacent tissues provide palliative relief to about 50% of the patients but little lifetime benefit is achieved.
The most important invasive palliation is the resolution of icterus by biliary duct stenting in association with endoscopic retrograde cholangiopancreatography (ERCP).

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).

Halbrook CJ, Lyssiotis CA, Pasca di Magliano M, et al. Pancreatic cancer: Advances and challenges. Cell 2023;186(8):1729-1754.[PubMed]
Park W, Chawla A, O'Reilly EM. Pancreatic Cancer: A Review. JAMA 2021;326(9):851-862.[PubMed]