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PauliPuolakkainen

Carcinoma of the Pancreas

Essentials

  • 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).