A Synopsis of AFP's "Diagnosis and Management of Pancreatic Cancer"

A synopsis of 
Diagnosis and Management of Pancreatic Cancer
MARIA SYL D. DE LA CRUZ, MD, Thomas Jefferson University, Philadelphia, Pennsylvania
ALISA P. YOUNG, MD, and MACK T. RUFFIN, IV, MD, MPH, University of Michigan School of Medicine, Ann Arbor, MichiganAm Fam Physician. 2014 Apr 15;89(8):62

     Pancreatic cancer is the fourth leading cause of cancer related deaths. Risk factors include family history, peutz-Jeghers syndrome, cystic fibrosis, chronic pancreatitis, tobacco use, HNPCC, BRCA1/2 carrier, obesity, and alcohol use. Screening for pancreatic cancer is not recommended at this time, although high risk patients may benefit from it. Symptoms vary according to tumor location and include pain, jaundice, itching, weight loss, anorexia, depression, dark colored urine, and acholic stool. 90% are ductal adenocarcinomas, with two thirds occurring in the pancreatic head. Signs include Courvoisier sign, Virchow node, Trousseau sign, cachexia, and abdominal tenderness. 

     An abdominal ultrasound is the first type of imagining typically performed. MRI, CT, and MRCP may be done secondarily. Pancreatic cysts require fine-needle aspiration. If metastasis is considered, a conformational biopsy is needed. Otherwise, a chest CT and liver function tests may be helpful. Cancer antigen 19-9 is a tumor marker for ductal adenocarcinoma. As with most cancer, detection at an early stage has the best outcome. 

     The only curative treatment is resection. This can be done in about 15-20% of the patients, but the 5 year survival is only 20%. The surgery is called a pancreaticoduodenectomy (whipple procedure). The resection includes the head of the pancreas, the second portion of the duodenum, the common bile duct, the gallbladder, and sometimes the distal stomach. Tumors in the tail or body of the pancreas are not resectable. Adjuvant treatment includes gemcitabine or fluorouracil/leucovorin, which can prolong survival by 2-3 months.  For the 80% of the patients who have cancer that is not resectable, chemotherapy and consolidation chemoradiation is used. One option is to use gemcitabine or fluorouracil with radiation.  Other therapies include irinotecan, cisplatin, or oxaliplatin (as monotherapy or in combination). Radiotherapy can be used in combination or alone. It is directed at the cancerous tissue to spare healthy tissue. The dose is dependent on patient tolerance. 

     Palliative care is considered for patients with advanced disease causing biliary obstruction, gastric outlet obstruction, malnutrition and depression. For patients with gastric outlet obstruction, an enteral stent can be used.  Gastrojejunostomy can be used in patients with a longer life expectancy. 

     Patients with successful cancer resection can be followed up with a physical exam every 3 to 6 months for two years and then annually. CA 19–9 CT and ultrasound can also be used for surveillance.