Pancreatic cancer is a malignant neoplasm originating from transformed cells arising in tissues forming the pancreas.

The most common type of pancreatic cancer, accounting for 95% of these tumors, is adenocarcinoma (tumors exhibiting glandular architecture on light microscopy) arising within the exocrine component of the pancreas.

A minority arise from islet cells and are classified as neuroendocrine tumors.

The signs and symptoms that eventually lead to the diagnosis depend on the location, the size, and the tissue type of the tumor, and may include abdominal pain, lower back pain, and jaundice (if the tumor compresses the bile duct), unexplained weight loss, and digestive problems.

Pancreatic cancer is the fourth most common cause of cancer-related deaths in the United States and the twelfth worldwide.

Pancreatic cancer has an extremely poor prognosis: for all stages combined, the 1- and 5-year relative survival rates are 25% and 6%, respectively; for local disease, the 5-year survival is approximately 15% while the median survival for locally advanced and for metastatic disease, which collectively represents over 80% of individuals, is about 10 and 6 months respectively.

Individuals vary, however – some are only diagnosed when they are already terminally ill and therefore only have a few days or weeks.

Others have slower progression and may live a couple of years even if surgery is not possible. Men are 30% more likely to get pancreatic cancer than are women.

Signs and symptoms

Early pancreatic cancer often does not cause symptoms, and the later symptoms are usually nonspecific and varied. Therefore, pancreatic cancer is often not diagnosed until it is advanced.

Common symptoms include:

Pain in the upper abdomen that typically radiates to the back (seen in carcinoma of the body or tail of the pancreas)

Heartburn – acid stomach

Poor appetite or nausea and vomiting

Diarrhea, loose stools.

Significant weight loss (cachexia)

Painless jaundice (yellow tint to whites of eyes (sclera) or yellowish skin, possibly in combination with darkened urine when cancer of the head of the pancreas (75% of cases) obstructs the common bile duct as it runs through the pancreas.

This may also cause a pale-colored stool and steatorrhea (presence of excess fat in feces). Jaundice may be associated with itching as the salt from excess bile can cause skin irritation.

Trousseau syndrome, in which blood clots form spontaneously in the portal blood vessels, the deep veins of the extremities, or the superficial veins anywhere on the body, may be associated with pancreatic cancer.

Pulmonary embolisms due to pancreatic cancers producing blood-clotting chemicals.

Diabetes mellitus, or elevated blood sugar levels. Many patients with pancreatic cancer develop diabetes months to even years before they are diagnosed with pancreatic cancer, suggesting new-onset diabetes in an elderly individual may be an early warning sign of pancreatic cancer.

Clinical depression has been reported in association with pancreatic cancer, sometimes presenting before the cancer is diagnosed. However, the mechanism for this association is not known.

Symptoms of pancreatic cancer metastasis.

Typically, pancreatic cancer first metastasizes to regional lymph nodes, and later to the liver or to the peritoneal cavity and, rarely, to the lungs; it rarely metastasizes to bone or brain.

Most patients with pancreatic cancer experience pain, weight loss, or jaundice.

Pain is present in 80% to 85% of patients with locally advanced or advanced metastatic disease. The pain is usually felt in the upper abdomen as a dull ache that radiates straight through to the back.

It may be intermittent and made worse by eating. Weight loss can be profound; it can be associated with anorexia, early satiety, diarrhea, or steatorrhea.

Jaundice is often accompanied by pruritus and dark urine. Painful jaundice is present in approximately one-half of patients with locally unresectable disease, while painless jaundice is present in approximately one-half of patients with a potentially resectable and curable lesion.

The initial presentation varies according to the location of cancer. Malignancies in the pancreatic body or tail usually present with pain and weight loss, while those in the head of the gland typically present with steatorrhea, weight loss, and jaundice.

The recent onset of atypical diabetes mellitus, a history of recent but unexplained thrombophlebitis (Trousseau sign), or a previous attack of pancreatitis is sometimes noted.

Courvoisier sign defines the presence of jaundice and a painlessly distended gallbladder as strongly indicative of pancreatic cancer and may be used to distinguish pancreatic cancer from gallstones.

Tiredness, irritability, and difficulty eating because of pain also exist. Pancreatic cancer is often discovered during the course of the evaluation of the aforementioned symptoms.

Liver function tests can show a combination of results indicative of bile duct obstruction. Imaging studies, such as computed tomography (CT scan) and endoscopic ultrasound (EUS) can be used to identify the location and form of cancer.

The definitive diagnosis is made by an endoscopic needle biopsy or surgical excision of the radiologically suspicious tissue. Endoscopic ultrasound is often used to visually guide the needle biopsy procedure.

Nonetheless, pancreatic cancer is usually staged using a CT scan. In fact, histologic diagnosis is not usually required for resection of the tumor, rather histologic analysis helps determine which chemotherapeutic regimen to start.

Treatment of pancreatic cancer depends on the stage of cancer. Although only localized cancer is considered suitable for surgery with curative intent at present, only 20% of cases present with localized disease at diagnosis.

Surgery can also be performed for palliation if the malignancy is invading or compressing the duodenum or colon. In such cases, bypass surgery might overcome the obstruction and improve quality of life but is not intended as a cure.

The Whipple procedure is the most common attempted curative surgical treatment for cancers involving the head of the pancreas.

This procedure involves removing the pancreatic head and the curve of the duodenum together (pancreatoduodenectomy), making a bypass for food from stomach to jejunum (gastro-jejunostomy) and attaching a loop of jejunum to the cystic duct to drain bile (cholecysto-jejunostomy).

It can be performed only if the patient is likely to survive major surgery and if the cancer is localized without invading local structures or metastasizing. It can, therefore, be performed in only a minority of cases.

Cancers of the tail of the pancreas can be resected using a procedure known as a distal pancreatectomy. Recently, localized cancers of the pancreas have been resected using minimally invasive (laparoscopic) approaches.

After surgery, adjuvant chemotherapy with gemcitabine has been shown in several large randomized studies to significantly increase the 5-year survival (from approximately 10 to 20%) and should be offered if the patient is fit after surgery.

Those with inoperable pancreatic cancer may have significant abdominal pain. A celiac plexus block (CPB), which destroys the nerves that transmit pain from the abdomen, is a safe and effective way to reduce the pain. CPB generally reduces the need to use pain killers like opioids, which have significant negative side effects.



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