Pancreatic cancer
Pancreatic ductal adenocarcinoma usually presents late, with painless obstructive jaundice from a head-of-pancreas mass, weight loss, and sometimes new-onset diabetes or migratory thrombophlebitis. Pancreas-protocol CT defines resectability, endoscopic ultrasound with fine-needle aspiration confirms tissue diagnosis, and only complete surgical resection with pancreaticoduodenectomy offers a chance of cure, which most patients cannot receive.
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What this article covers
- Overview
Definition: pancreatic cancer is most often ductal adenocarcinoma arising from the exocrine pancreas, about 90% of pancreatic neoplasms, typically diagnosed late because early disease is silent.
- Epidemiology
Incidence and mortality: approximately 57,000 new cases and 46,000 deaths annually in the United States; currently the third leading cause of cancer-related death, projected to become the second within the next decade.
- Risk factors
Cigarette smoking: the strongest modifiable risk factor.
- Pathophysiology
Stepwise ductal carcinogenesis: most tumors evolve through pancreatic intraepithelial neoplasia, a progressive sequence of dysplastic ductal lesions accumulating driver mutations before invasive cancer emerges.
- Clinical features
Painless obstructive jaundice: scleral icterus, dark urine, and pale (acholic) stools from bile duct compression by a head-of-pancreas mass, classically without biliary colic.
- Differential diagnosis
Choledocholithiasis: obstructive jaundice and cholestatic labs, but typically with biliary colic and gallstones on imaging rather than a discrete mass (Choledocholithiasis).
- Diagnosis
A pancreatic mass on cross-sectional imaging with tissue confirmation establishes the diagnosis; there is no clinical diagnostic criteria set.
- Management
Determine resectability first, since it dictates the pathway: resectable disease to surgery, borderline resectable disease to neoadjuvant therapy with reassessment for surgery, locally advanced or…
- Complications
Biliary obstruction: jaundice, pruritus, cholangitis if the obstructed system becomes infected, and hepatic dysfunction.
- Prognosis
Resectability is the dominant determinant of outcome: only patients able to undergo a complete (R0) resection have a realistic chance of cure.
- Prevention
No average-risk population screening: the American Gastroenterological Association and International Cancer of the Pancreas Screening Consortium recommend against screening average-risk individuals…
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Related articles
- Chronic pancreatitis
Chronic pancreatitis is irreversible fibro-inflammatory destruction of the pancreas that produces abdominal pain along with exocrine and endocrine insufficiency, most often from long-term alcohol use in adults and cystic fibrosis in children. Diagnosis rests on CT or MRI showing calcifications and ductal change, and management combines alcohol and tobacco cessation, staged analgesia, pancreatic enzyme replacement, and endoscopic or surgical drainage for ductal obstruction.
- Acute pancreatitis
Acute pancreatitis is acinar-cell autodigestion and inflammation of the pancreas, most often from gallstones or alcohol, diagnosed by the revised Atlanta criteria and graded mild, moderately severe, or severe by organ failure. Management centers on early goal-directed lactated Ringer's resuscitation, analgesia, early enteral feeding, and timed ERCP for gallstone pancreatitis with cholangitis, reserving antibiotics for confirmed infected necrosis.
- Choledocholithiasis
Choledocholithiasis is a gallstone that has migrated into the common bile duct, causing obstructive jaundice and cholestatic liver chemistries and predisposing to acute cholangitis and gallstone pancreatitis. Risk is stratified by ASGE criteria and confirmed by MRCP, endoscopic ultrasound, or therapeutic ERCP, which clears the duct before same-admission cholecystectomy.
- Pancreatic neuroendocrine tumors (PanNETs)
Pancreatic neuroendocrine tumors (PanNETs) are islet-cell tumors that may be functional, producing a hormone-excess syndrome such as insulinoma or gastrinoma, or nonfunctioning and detected by mass effect or incidentally. First-line treatment is surgical resection when localized, with somatostatin analogues and acid suppression used to control hormone-excess symptoms before or in place of surgery.
- Type 2 diabetes mellitus
Type 2 diabetes is hyperglycemia from insulin resistance with progressive relative insulin deficiency, diagnosed by a hemoglobin A1c of 6.5% or higher, a fasting glucose of 126 mg/dL or higher, or a 2-hour oral glucose tolerance test value of 200 mg/dL or higher. First-line treatment is lifestyle modification plus metformin, with an SGLT2 inhibitor or GLP-1 receptor agonist added early for patients with atherosclerotic disease, kidney disease, or heart failure.
- Smoking cessation
Tobacco use is the leading cause of preventable death in the United States, and every smoker should be asked about use at every visit and offered combined behavioral counseling plus pharmacotherapy, since neither alone matches the quit rate of both together. Varenicline is the most effective single agent, combination nicotine replacement therapy (long-acting patch plus a short-acting form) is equally first-line, and bupropion is an alternative, all started before a set quit date and continued for a 7- to 12-week course.