The latest article in our Medical Progress review series, Pancreatic Cancer, comes from Manueal Hidalgo, M.D. of the Centro Nacional de Investigaciones Oncológicas and Hospital de Madrid and Johns Hopkins University School of Medicine.
Deaths from pancreatic ductal adenocarcinoma, also known as pancreatic cancer, rank fourth among cancer-related deaths in the United States. In 2008, the estimated incidence of pancreatic cancer in the United States was 37,700 cases, and 34,300 patients died from the disease. Pancreatic cancer is more common in elderly persons than in younger persons, and less than 20% of patients present with localized, potentially curable tumors. The overall 5-year survival rate among patients with pancreatic cancer is 5%.
Clinical Pearls
• How do patients with pancreatic cancer typically present?
The presenting symptoms of pancreatic cancer depend on the location of the tumor within the gland, as well as on the stage of the disease. The majority of tumors develop in the head of the pancreas and cause obstructive cholestasis. Vague abdominal discomfort and nausea are also common. Pancreatic cancer often causes dull, deep upper abdominal pain that broadly localizes to the tumor area. Obstruction of the pancreatic duct may lead to pancreatitis. Patients with pancreatic cancer often have dysglycemia. At presentation, most patients also have systemic manifestations of the disease such as asthenia, anorexia, and weight loss. Other, less common manifestations include deep and superficial venous thrombosis, panniculitis, liver-function abnormalities, gastric-outlet obstruction, increased abdominal girth, and depression.
• How should patients in whom pancreatic cancer is suspected be evaluated?
Evaluation of a patient in whom pancreatic cancer is suspected should focus on diagnosis and staging of the disease, assessment of resectability, and palliation of symptoms. Multiphase, multidetector helical computed tomography (CT) with intravenous administration of contrast material is the imaging procedure of choice for the initial evaluation. This technique allows visualization of the primary tumor in relation to the superior mesenteric artery, celiac axis, superior mesenteric vein, and portal vein and also in relation to distant organs. Endoscopy is the preferred method of obtaining tissue for diagnostic purposes. Although a preoperative tissue diagnosis is not needed in patients who are scheduled for surgery, it is required before the initiation of treatment with chemotherapy or radiation therapy.
Morning Report Questions
Q: How should patients with early disease be managed?
A: Patients with pancreatic cancer are best cared for by multidisciplinary teams that include surgeons, medical and radiation oncologists, radiologists, gastroenterologists, nutritionists, and pain specialists, among others. For patients with resectable disease, surgery remains the treatment of choice. Depending on the location of the tumor, the operative procedures may involve cephalic pancreatoduodenectomy (the Whipple procedure), distal pancreatectomy, or total pancreatectomy. A minimum of 12 to 15 lymph nodes should be resected, and every attempt should be made to obtain a tumor-free margin. Even if the tumor is fully resected, the outcome in patients with early pancreatic cancer is disappointing.
Q: How should patients with advanced disease be managed?
A: The treatment of patients with advanced disease remains palliative. A meta-analysis of published findings from clinical trials showed an improvement in survival among patients who received chemotherapy; these findings suggest that active treatment is beneficial. At the present time, the standard approach for patients with advanced disease ranges from gemcitabine given alone to gemcitabine combined with either erlotinib, a platinum agent, or a fluoropyrimidine.
Figure 2. Pathological, Radiologic, and Histologic Features of Pancreatic Cancer.
