Pancreatic cancer: Clinical sciences

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. 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. 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. 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.