Pancreatic cancer: Clinical sciences

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Introduction0:00–0:44

Pancreatic cancer is most commonly adenocarcinoma, though there are some other rare types such as neuroendocrine or lymphoma.
Pancreatic adenocarcinomas are exocrine tumors and are most often located in the head of the pancreas. Unfortunately, pancreatic cancer has an insidious onset, making it difficult to detect.
Staging is based on tumor size, invasion of lymph nodes or nearby structures like major blood vessels, and presence or absence of distant spread and metastasis.
Staging ultimately determines if the tumor is resectable or not.The first step in evaluating a patient with signs and symptoms suggestive of pancreatic cancer is to obtain a focused history and physical examination.

Red flags and acute management0:44–2:10

Now, the tumor might grow large enough to compress or invade the biliary tree and cause biliary obstruction and cholangitis.
Because of this, you should be on the lookout for any red flags, which are actually signs of biliary obstruction and cholangitis.
These include fever, severe jaundice with pruritus, altered mental status, and signs of sepsis such as tachycardia and hypotension.
If any of these signs are present, you must first stabilize the patient. This means that you might need to secure the airway, provide supplemental oxygen, establish IV access, and consider starting broad-spectrum IV antibiotics.
In addition, order an ultrasound to rule out gallstones, as well as a CT scan to evaluate the site and cause of biliary obstruction.
Next, because the mortality rate associated with biliary obstruction is high, you’ll have to relieve the obstruction before proceeding with further diagnostic workup.
To do this, you should order an emergent ERCP with stenting to actually diagnose the obstruction and treat it immediately.
However, if the patient can’t undergo ERCP with stenting, place a percutaneous cholecystostomy tube instead. Now, let’s switch gears and talk about patients without red flags.

History and Physical2:10–4:01

Because most pancreatic cancers are insidious, patients usually present with non-specific symptoms, such as fatigue, anorexia, weight loss, and painless jaundice; while epigastric and back pain can occur with tumor invasion.
Additionally, the history might reveal some important risk factors, like biological male sex, age over 55, and smoking, as well as having diabetes or chronic pancreatitis.
Then, the physical exam might reveal cachexia, as well as hepatomegaly, ascites, or a firm, fixed, palpable, nontender epigastric mass.
Some important signs you may see include Courvoisier sign, which is characterized by obstructive jaundice with a palpable, nontender gallbladder; as well as Trousseau syndrome, also known as migratory thrombophlebitis, where the patient may develop recurrent blood clots that cause venous inflammation, leading to redness and tenderness of the limbs.Some high-yield facts to keep in mind!
Some pancreatic cancers arise from genetic mutations that can be associated with cancer syndromes. Therefore, if a patient has a personal or family history of cancer syndromes like Lynch syndrome, Peutz-Jeghers syndrome, or von Hippel-Lindau syndrome, your clinical suspicion of pancreatic cancer must be high.If the history and physical examination suggest pancreatic cancer, you should obtain baseline labs, including bilirubin, liver function tests or LFTs, and the tumor marker CA19-9; and order a CT of the abdomen and pelvis.

Pancreatic cancer staging4:01–8:19

Alright, now that you’ve ordered some diagnostic tests, let’s talk about how to use them to stage the cancer. Labs will usually reveal elevated bilirubin and LFTs, as well as positive CA 19-9, Keep in mind that tumor markers like CA 19-9 are not used to diagnose the cancer, but to establish a baseline level, which will help you monitor the treatment response and assess for recurrence in the future.
If a pancreatic mass is visualized on CT, you should move on to endoscopic ultrasound or CT-guided tissue biopsy, which can confirm the diagnosis of pancreatic cancer.
Then, the next step is to stage the tumor with CT, MRI, or PET CT.Cancer staging is based on the TNM system, which stands for Tumor size and extent, spread to lymph Nodes, and Metastasis or spread to distant parts of the body.
The treatment depends on the stage of the tumor. In general, early stage cancers can be resected with surgery, while advanced stage cancers may require different combinations of chemotherapy, radiation, and surgery when possible.Alright, let’s go back to TNM staging, which will determine the treatment.
The main thing you want to determine is if the tumor is surgically resectable, borderline resectable, or unresectable. Now, if you see on imaging a contained pancreatic mass without any evidence of distant metastasis, the patient may be a candidate for surgical resection.
It is important to send the resected mass for pathologic confirmation of clear margins. If the mass was not completely resected, or lymph nodes are positive for cancer cells, you can consider offering adjuvant chemoradiation therapy.On the flip side, some tumors are considered “borderline” resectable if they have locally grown into nearby tissues, but still haven’t developed distant metastasis.
In this case, start the patient on neoadjuvant chemoradiation therapy to shrink the tumor in an attempt to make it resectable.
Once the patient completes a full course of neoadjuvant chemoradiation, obtain a follow-up CT or MRI to see if the tumor shrunk.
If the tumor is now smaller and surgically resectable, surgical excision is the next step, followed by another course of chemoradiation, which is now referred to as adjuvant chemoradiation.
However, if there is no change or minimal change after neoadjuvant therapy and the tumor is unresectable, you can offer a different type of chemotherapy or see if you can enroll them in a clinical trial for a new therapeutic drug.
You must follow these patients closely to monitor symptoms, obtain routine CT or MRI to assess for improvement as well as provide any supportive care if needed.
Lastly, some tumors are considered surgically unresectable. This includes tumors that involve, encase, or occlude a major peripancreatic vessel; as well as those with distant metastasis.
Because of the poor prognosis, chemotherapy is usually palliative in this case. You should also start supportive care, such as pain medications, antiemetics for nausea, and psychotherapy.
Finally, consider palliative care as needed, and if the biliary ducts are compressed or obstructed, make sure to offer an ERCP for palliative biliary stenting.Finally, let’s go back to our initial labs and CT.
If labs reveal normal or elevated bilirubin and LFTs, but the tumor marker CA 19-9 is negative, and no pancreatic mass is seen on CT, then it’s probably a good idea to consider alternative diagnoses.
These include chronic pancreatitis, hepatitis, or other cancers like colorectal or breast cancer. Alright, as a quick recap… Pancreatic cancer has an insidious onset, making it difficult to detect.

Review8:19–9:29

Patients with red flags on history or physical exam require emergent ERCP with biliary stenting before doing any other assessments.
On the other hand, for patients without red flags, you should obtain baseline labs and order a CT. If the tumor is visible on imaging, the next step is to obtain an endoscopic ultrasound or CT-guided tissue biopsy, which will confirm the diagnosis, followed by TNM staging with CT, MRI, or PET CT.
Now, if there are no distant metastases and it’s limited to the pancreas, the tumor should be considered for surgical resection.
For borderline resectable tumors, treatment involves chemoradiation to shrink the tumor, followed by surgical resection if possible.
Unresectable tumors include those that encase or occlude large blood vessels, as well as those with distant metastases; their treatment is usually palliative, including chemoradiation and supportive management such as
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