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PostSubject: pancreatic cancer diagnosis   Mon Aug 29, 2011 9:26 pm

pancreatic cancer diagnosis



Pancreatic Cancer: Diagnosis and Management
ROBERT FREELOVE, M.D.,Smoky Hill Family Medicine Residency Program, Salina, Kansas
ANNE D. WALLING, M.B., CH.B.,University of Kansas School of Medicine-Wichita, Wichita, Kansas
Am Fam Physician. 2006 Feb 1;73(3):485-492.

Although only 32,000 new cases of adenocarcinoma of the pancreas
occur in the United States each year, it is the fourth leading cause of
cancer deaths in this country. The overall five-year survival rate is 4
percent, and localized, resectable disease has only a 17 percent
survival rate. Risk factors include smoking, certain familial cancer
syndromes, and familial chronic pancreatitis. The link between risk of
pancreatic cancer and other factors (e.g., diabetes, obesity) is less
clear. Most patients present with obstructive jaundice caused by
compression of the bile duct in the head of the pancreas. Epigastric or
back pain, vague abdominal symptoms, and weight loss also are
characteristic of pancreatic cancer. More than one half of cases have
distant metastasis at diagnosis. Computed tomography is the most useful
diagnostic and staging tool. Ultrasonography, magnetic resonance
imaging, and endoscopic retrograde cholangiopancreatography may provide
additional information. The majority of tumors are not surgically
resectable because of metastasis and invasion of the major vessels
posterior to the pancreas. Resectable tumors are treated with the
Whipple procedure or the pylorus-preserving Whipple procedure. Adjuvant
fluorouracil-based chemotherapy may prolong survival. For nonresectable
tumors, chemotherapy with gemcitabine prolongs survival. Other agents
are being studied. Radiation combined with chemotherapy has slowed
progression in locally advanced cancers. Throughout the illness and
during end-of-life care, patients need comprehensive symptom control.


The American Cancer
Society estimated that 31,860 Americans would be diagnosed with
pancreatic cancer in 2004, and that 31,270 would die from the disease.1
Pancreatic cancer accounts for only 2 percent of all new cancers in the
United States, but it is the fourth leading cause of cancer deaths. At
the time of diagnosis, more than one half of pancreatic cancers have
metastasized, and only 8 percent are localized. The overall five-year
survival rate is 4 percent. Localized cancers have a 17 percent survival
rate. Survival rates have not improved during the past 25 years.1

Pancreatic cancer rarely
occurs in persons younger than 50 years, and the risk increases with
age. The incidence of pancreatic cancer is declining slowly in white
men, but it is increasing in other groups, possibly because of changes
in smoking patterns. Women account for 57 percent of new cases.1 Smoking,2 diabetes,3 and obesity4 increase risk. A link between alcohol or coffee consumption and pancreatic cancer has not been verified.5 Physical activity; high fruit and vegetable intake6; and, possibly, nonsteroidal anti-inflammatory drugs reduce the risk.7 Up to 10 percent of patients report a family history of pancreatic cancer.8 Patients with rare familial cancer syndromes or hereditary chronic pancreatitis have a substantially increased risk.9 Research on overexpression of specific oncogenes10
and reduced activity of tumor suppressor genes may provide a better
understanding of the pathogenesis of pancreatic cancer and lead the way
to more effective screening tests.11,12


SORT: KEY RECOMMENDATIONS FOR PRACTICE


Clinical recommendationEvidence ratingReferences
Dual-phase
helical computed tomography is the best initial imaging test for
diagnosis and staging of suspected pancreatic carcinoma.
C
21,26,27
Patients
undergoing resection for pancreatic cancer should be offered referral
to high-volume hospitals (i.e., performing more than 16 Whipple
procedures per year) where there is less risk of perioperative
mortality.
B
33
Adjuvant
chemotherapy with fluorouracil and leucovorin improves survival rates
and should be offered to patients with resectable pancreatic cancer.
B
28
Gemcitabine (Gemzar) is recommended as first-line chemotherapy for patients with metastatic pancreatic cancer.
B
42
Fluorouracil-based chemoradiation therapy is recommended for patients with locally advanced pancreatic cancer.
B
4547
Endoscopicguided
palliative intervention for pancreatic cancer, including celiac plexus
neurolysis for pain and stenting for biliary or gastric outlet or
duodenal obstruction, is effective and avoids the risks of surgery.
B
4951

A
= consistent, good-quality patient-oriented evidence; B = inconsistent
or limited-quality patient-oriented evidence; C = consensus,
disease-oriented evidence, usual practice, expert opinion, or case
series. For more information about the SORT evidence rating system, see
page 374 or
http://www.aafp.org/afpsort.xml.




Clinical Presentation

Almost all pancreatic
cancers are adenocarcinomas of the ductal epithelium, and symptoms
primarily are caused by mass effect rather than disruption of exocrine
or endocrine function. The clinical features depend on the size and
location of the tumor as well as its metastases. Jaundice, pain, and
weight loss are classic symptoms of pancreatic cancer. Nonspecific early
symptoms often are unrecognized; therefore, most pancreatic cancers are
advanced at diagnosis (Table 1).13 More than two thirds of pancreatic cancers occur in the head of the pancreas (Figure 1)
and usually present as steadily increasing jaundice caused by biliary
duct obstruction. Painless obstructive jaundice traditionally is
associated with surgically resectable cancers.14
Obstruction of the bile duct causes jaundice with disproportionately
increased levels of conjugated bilirubin and alkaline phosphatase in the
blood. The urine is dark because of the high level of conjugated
bilirubin and the absence of urobilinogen. The stool is pale because of
the lack of stercobilinogen in the bowel. In addition to jaundice,
rising bilirubin levels can cause severe pruritus. As hepatic function
becomes compromised, patients experience fatigue, anorexia, and bruising
caused by loss of clotting factors.


TABLE 1

Prevalence of Pancreatic Cancer Symptoms*

Head of the pancreasBody and tail of the pancreasSymptomsPatients (%)SymptomsPatients (%)
Weight loss
92
Weight loss
100
Jaundice
82
Pain
87
Pain
72
Nausea
43
Anorexia
64
Weakness
42
Dark urine
63
Vomiting
37
Light stool
62
Anorexia
33
Nausea
45
Constipation
27
Vomiting
37
Food intolerance
7
Weakness
35
Jaundice
7

*—Symptoms listed in order of prevalence.

Adapted
with permission from DiMagno EP. Cancer of the pancreas and biliary
tract. In: Winawer SJ, ed. Management of gastrointestinal diseases. New
York: Gower Medical Publishing, 1992.






Figure 1.
Pancreatic head mass(arrow) in a 58-year-old man presenting with vague abdominal pain and jaundice. Radiographic view(A). Anatomic drawing(B).

Patients
with tumors in the body and tail of the pancreas generally present with
nonspecific pain and weight loss. Body and tail tumors are much less
likely to cause obstructive signs and symptoms. Patients may have pain
in the epigastrium or back ranging from a dull ache to a severe pain.
The pain may be exacerbated by eating or by lying flat. Tumors in the
body and tail usually do not cause symptoms until they are large (Figure 2), and most present as locally advanced disease extending to the peritoneum and spleen.





Figure 2.
Large pancreatic tail mass(arrow) in a 63-year-old woman presenting with abdominal discomfort and a palpable mass. Radiographic view(A). Anatomic drawing(B).

Unexplained
weight loss of about 5 lb (2.3 kg) per month may be the presenting
feature of pancreatic cancer. Weight loss may be caused or exacerbated
by anorexia, diarrhea, or early satiety. Obstruction of the pancreatic
duct causes steatorrhea, exacerbating weight loss and malnutrition.
Patients commonly become cachectic as the disease progresses.


PHYSICAL EXAMINATION

Other than jaundice,
weight loss, and bruising, physical examination findings may be normal. A
distended, palpable but nontender gallbladder in a jaundiced patient
(Courvoisier’s sign) is 83 to 90 percent specific but only 26 to 55
percent sensitive for malignant obstruction of the bile duct.15
Although Courvoisier’s sign increases the likelihood of malignancy,
absence of the sign does not rule it out. The liver may be tender and
enlarged with advanced disease, and patients may present with ascites,
palmar erythema, and spider angioma. Other findings associated with
advanced pancreatic cancer or other abdominal malignancies include left
supraclavicular lymphadenopathy (Virchow’s node) and recurring
superficial thrombophlebitis (Trousseau’s sign).




Diagnostic Tests

A patient history,
physical examination, and serum bilirubin and alkaline phosphatase
levels can point to pancreatic cancer, but they are not diagnostic. The
serum tumor marker cancer antigen (CA) 19–9 may help confirm the
diagnosis in symptomatic patients16 and may help predict prognosis and recurrence after resection.17
However, CA 19–9 lacks sufficient sensitivity (50 to 75 percent) and
specificity (83 percent) to effectively screen asymptomatic patients.
Recent data18
suggest the serum tumor markers beta subunit of human chorionic
gonadotropin (beta-hCG) and CA 72–4 are stronger independent prognostic
factors than CA 19–9.

The U.S. Preventive
Services Task Force (USPSTF) does not recommend screening average-risk,
asymptomatic patients with abdominal palpation, ultrasonography, or
serologic tumor markers.19
Although regular screening with endoscopic ultrasonography may be
cost-effective in patients with a family history of pancreatic cancer,20
the USPSTF has not addressed the question of screening these patients.
The accuracy of imaging studies for suspected pancreatic malignancy is
summarized in Table 2.2125

TABLE 2

Accuracy of Imaging Studies for the Diagnosis of Pancreatic Cancer

Percentage of patients with pancreatic cancer at 10 percent pretest probability*Percentage of patients with pancreatic cancer at 30 percent pretest probability*Imaging studySensitivity †(%)Specificity ‡(%)Abnormal (%)Normal (%)Abnormal (%)Normal (%)
Dual-phase helical computed tomography
98
54
19
0.4
48
2
Transabdominal ultrasonography
83
99
90
1.9
97
7
Endoscopic ultrasonographyguided fine-needle aspiration
92
100
95
0.9
99
3
Endoscopic retrograde cholangiopancreatography
70
94
56
3.4
83
12
Magnetic resonance cholangiopancreatography
84
97
76
1.8
92
7
Positron emission tomography
96
65
23
0.7
54
3

*—Estimated likelihood of pancreatic cancer before testing.

†—Percentage of patients with pancreatic cancer who have an abnormal test.

‡—Percentage of patients without pancreatic cancer who have a normal test.

Information from references21 through25.




Although conventional
computed tomography (CT) and transabdominal ultrasonography are
appropriate for initial imaging, dual-phase helical CT scanning is the
best option if available. Dual-phase helical CT is the most sensitive
test, and it noninvasively identifies 98 percent of pancreatic cancers
and distant metastases, providing diagnostic and staging information.2126 If CT is indeterminate or negative and clinical suspicion remains high, endoscopic ultrasonography should be performed next.27
A fine-needle aspiration biopsy guided by endoscopic ultrasonography
may provide tissue diagnosis in patients who are not surgical
candidates.23
Patients with resectable disease who are surgical candidates can
undergo definitive surgery without preoperative histologic confirmation.
Magnetic resonance imaging is not used in typical clinical practice,
and it is less sensitive than CT (i.e., similar in sensitivity to
transabdominal ultrasonography). Once a mainstay in diagnostic imaging
and tissue sampling, endoscopic retrograde cholangiopancreatography
(ERCP) is used only when other modalities are inconclusive and suspicion
for malignancy is high or when delineation of the biliary tree is
crucial. ERCP also is appropriate when stent placement to relieve
biliary obstruction is a consideration.12


Staging

Accurate staging is
important in identifying surgical candidates and sparing noncandidates
the risk and cost associated with surgery. Unresectable disease is
defined by distant metastasis (e.g., hepatic, extra-abdominal,
peritoneum, omentum, lymph nodes outside the resection zone); invasion
of superior mesenteric artery, inferior vena cava, aorta, or celiac
axis; or encasement or occlusion of the superior mesentericportal venous
complex.12

The tumor, node, and
metastasis system may be used for pancreatic cancer staging, but in
clinical decision making, pancreatic cancers can be categorized as
resectable, locally advanced, or metastatic (Table 3).28,29
Staging begins with a thorough history and physical examination to find
evidence of metastatic disease. Initial imaging with dual-phase helical
CT of the abdomen and pelvis is the best way to assess most tumors and
identify distant metastases and arterial involvement.26
If the patient has high surgical risk, or if CT shows unrsectable
disease, fine-needle aspiration can confirm the diagnosis, and no
further staging work-up is necessary.23
If the CT scan is indeterminate, endoscopic ultrasonography can
identify smaller lesions and further delineate vascular involvement.30
Staging laparoscopy generally is reserved for patients whose physicians
highly suspect metastasis but have not yet identified it.12,31

TABLE 3

Tumor, Node, Metastasis Staging System for Pancreatic Cancer

StageClassificationsClinical classificationStage distribution at diagnosis (%)Five-year survival rate (%)
0
Tis, N0, M0
Resectable
7.5
15.2
IA
T1, N0, M0



IB
T2, N0, M0



IIA
T3, N0, M0



IIB
III
T1-3, N1*, M0
T4, any N, M0
Locally advanced
29.3
6.3
IV
Any T, any N, M1
Metastatic
47.2
1.6

Tis
= in situ carcinoma; N0 = no regional lymph node metastasis; M0 = no
distant metastasis; T1 = tumor is limited to the pancreas and is 0.8 in
(2 cm) or smaller; T 2 = tumor is limited to the pancreas and is larger
than 0.8 in; T3 = tumor extends beyond the pancreas and does not involve
celiac axis or superior mesenteric artery; N1 = regional lymph node
metastasis; T4 = tumor involves celiac axis or superior mesenteric
artery; N = regional lymph nodes; T = primary tumor; M1 = distant
metastasis.

*—Tumors
with regional lymph node involvement are sometimes considered
surgically resectable if nodes are within the resection area.

Information from references28 and29.





Treatment

Surgical resection is the
only potentially curative treatment for patients with pancreatic cancer,
although many patients are not candidates for resection.


RESECTABLE LESIONS

About 15 to 20 percent of patients with pancreatic adenocarcinoma have resectable disease at the time of diagnosis.12 The classic Whipple procedure (Figure 3)
involves removal of the head and uncinate process of the pancreas,
duodenum, proximal 6 in (15 cm) of jejunum, gallbladder, common bile
duct, and distal stomach, with anastomosis of the common hepatic duct
and the remaining pancreas and stomach to the jejunum.32
The perioperative mortality rate of patients undergoing this procedure
has improved significantly over the past three decades. Surgical teams
performing more than 16 procedures per year report significantly lower
perioperative mortality rates than centers with less experience (3.8
versus 7.5 to 17.6 percent).33




Figure 3.
The Whipple procedure. Before the procedure(A). After the procedure; note the anastomosis of the hepatic duct and the remaining pancreas and stomach to the jejunum(B).

Pyloruspreserving
pancreaticoduodenostomy appears to offer the same long-term survival
benefits as the standard Whipple procedure with shorter operative time
and reduced blood loss, decreasing the need for blood transfusions.34
Risks associated with both procedures include delayed gastric emptying,
pancreatic fistula, anastomotic leaks, wound infection, intraabdominal
abscess, hemorrhage, diabetes, and pancreatic exocrine insufficiency.34
Distal pancreatectomy is performed in patients with resectable cancer
in the body or tail of the pancreas. The spleen usually is removed as
well. The resectability rate for body and tail lesions is less than one
half of that for head lesions35
because diagnosis usually occurs late in the disease process after
local invasion has occurred. Five-year survival for resection of body or
tail lesions is similar to that of resection for pancreatic head
lesions.35 Five-year survival rates after surgical resection range from 10 to 30 percent.3641
Negative prognostic factors include poorly differentiated histology,
positive resection margins, lymph node involvement, and a tumor larger
than 0.8 in (2 cm).3638



Randomized clinical trials36,3941
evaluating the effectiveness of adjuvant chemoradiotherapy and
chemotherapy after surgical resection have been heavily criticized and
have had inconsistent results. Recent data,36
however, suggest adjuvant chemotherapy with leucovorin and fluorouracil
may increase survival, but adjuvant chemoradiotherapy offers no
survival benefit and may decrease survival when administered before
chemotherapy. Trials are underway to study postoperative chemotherapy
with f luorouracil and leucovorin or gemcitabine (Gemzar) and
chemotherapy with fluorouracil-based chemoradiation combined with
gemcitabine or fluorouracil.12


METASTATIC LESIONS

Researchers have studied
many single- and multiple-agent chemotherapeutic regimens for patients
with metastatic disease, and more studies are ongoing; however, few
studies have shown survival or clinical benefit. The use of gemcitabine
as first-line therapy has a 12-month survival advantage and improves or
stabilizes pain, performance status, and weight compared with
fluorouracil monotherapy.42
Although the combination of leucovorin and fluorouracil is effective as
adjuvant chemotherapy in resectable disease, it does not seem to be any
more effective than fluorouracil monotherapy for treatment of
unresectable disease.4344


LOCALLY ADVANCED LESIONS

External beam and
intraoperative radiation therapy decrease local progression in patients
with unresectable, locally advanced disease, but neither affects
survival or metastasis.45
Therefore, radiation therapy alone does not effectively treat patients
with locally advanced pancreatic cancer outside of palliation. Combined
radiation therapy and fluorouracil-based chemotherapy offer significant
survival improvement compared with radiation therapy alone (40 versus 10
percent survival after one year, number needed to treat = 3) and are
routinely used unless a patient is enrolled in an investigational study
of another treatment regimen.12,4547
Radiation with gemcitabine increases toxicity rates but does not
significantly impact survival compared with radiation and fluorouracil.48
Regardless of stage, the potential benefits of therapy for pancreatic
cancer must be balanced against the significant side effects, costs, and
quality-of-life factors.



PALLIATIVE CARE

Palliative treatment of
patients with pancreatic cancer is important, and involving hospice
early is appropriate. Patients should be monitored closely for
depression and treated when it arises. Othercomplications that require
palliative intervention include pain; gastric outlet or duodenal
obstruction; and bile duct obstruction and subsequent jaundice,
cachexia, and malabsorption caused by exocrine pancreatic insufficiency.


Exocrine pancreatic
insufficiency and subsequent malabsorption should be treated with
pancreatic enzyme replacement (30,000 IU) of pancrelipase before,
during, and after a meal, with increased titration as needed. Weight
loss unrelated to malabsorption generally is multifactorial and may be
treated with appetite stimulants (e.g., megestrol [Megace], dronabinol
[Marinol], corticosteroids) and a high-calorie diet or nutritional
supplements.

Pain from pancreatic
cancer can be managed with opioid analgesics, radiation therapy,
chemotherapy, or celiac plexus neurolysis (i.e., chemical
splanchnicectomy of the celiac plexus with alcohol). Celiac plexus
neurolysis eases pain without the side effects of opioids and can be
administered intraoperatively, percutaneously, or by endoscopic
ultrasonography. Endoscopic ultrasonography–guided neurolysis is
effective and has minimal risk of the potentially serious complications
associated with the surgical or percutaneous approaches.49

Biliary decompression for
palliation of jaundice can be achieved surgically through
choledochojejunostomy or cholecystojejunostomy. These procedures can be
performed at the same time as gastrojejunostomy, which can relieve
gastric outlet or duodenal obstruction. Biliary decompression also can
be achieved endoscopically using expandable wire stents. Endoscopic
placement of metal stents has a much lower risk than with surgery and
less stent occlusion than with plastic stent use.12,50
This method relieves obstructive symptoms in 97 percent of patients and
has morbidity and mortality rates of 12 and 3 percent, respectively.
Complications include bleeding, infection, and pancreatitis.50
Similarly, metal stent placement can effectively manage duodenal
obstruction in 81 percent of patients. Metal stents cost less and
require a shorter hospital stay than surgical treatment.51


The Authors
ROBERT
FREELOVE, M.D., is associate director of the Smoky Hill Family Medicine
Residency Program in Salina, Kan., and clinical instructor of family
and community medicine at the University of Kansas School of
Medicine-Wichita. Dr. Freelove received his medical degree from the
University of Kansas School of Medicine-Wichita and completed a family
practice residency with the Smoky Hill Family Medicine Residency
Program.

ANNE D. WALLING, M.B.,
CH.B., is professor of family and community medicine and associate dean
of faculty at the University of Kansas School of Medicine-Wichita. Dr.
Walling received her medical degree at the University of St. Andrews in
Scotland. She completed internships in Dundee, Scotland, and completed
postdoctoral training in community medicine in London, England.

Address
correspondence to Robert Freelove, M.D., Smoky Hill Family Medicine
Residency Program, 501 S. Santa Fe, #200, Salina, KS 67401 (e-mail:
rfreelove@salinahealth.org). Reprints are not available from the authors.
Author disclosure: Nothing to disclose.



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