Pancreatic Cancer. Presenting symptoms
Presenting symptoms: early symptoms are non-specific. Weight loss, anorexia, abdominal discomfort or pain. Jaundice can be an early or late presentation. A small subset of these patients with carcinomas of the head of the pancreas, the tumor will be located so that even at a small size it obstructs the common bile duct, and these are patients who present early with jaundice and are the most likely candidates for a surgical cure. The late symptoms: wasting and severe pain, perineoplasty, which we’ll get into. The severe pain of pancreatic cancer is sensed as abdominal pain radiating to the back. And it’s really a very major problem and it is almost universal in patients who develop advanced disease. More than once I’ve recognized in the waiting room a patient with pancreatic cancer because they are sitting there in their chair and they are leaning forward. The pain, the back pain of pancreatic cancer, is due to invasion of nerve structures behind the pancreas and it is somewhat relieved by leaning forward. It is susceptible to control by ablation, as we’ll come to later, by alcohol injection.
Disorders information
Signs at presentation: commonly, none. Patient will come in and say, “I’ve lost appetite, I’ve lost 10 pounds, I’ve got this vague abdominal pain.” You examine them and find nothing. Jaundice, abdominal mass, tenderness, hepatomegaly, ascites are all possible. A non-tender palpable gall bladder, Courvoisier’s sign, is sometimes seen. That’s not a very common finding but it’s striking when it’s there. Trousseau’s syndrome is the perineoplastic syndrome that we associate most with pancreatic cancer. Trousseau was a French physician. He described this syndrome in the French literature and died shortly thereafter, because he described it in himself. This is associated with mucinous adenocarcinomas. It’s not specific for pancreatic carcinoma. I see more of it in adenocarcinoma of the lung than I see in pancreatic cancer but it’s important to remember that this is procoagulant-induced. Mucins and certain species of mucins, are strong procoagulants, therefore cutting back on the factors by administering Coumadin is not going to be a very effective way to deal with this painful thrombophlebitis, and you really need heparin to manage it.
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Diagnosis: CT scan is the preferred study. This is supplemented by sonograms, ERCP and angiography in some selected cases helps the surgeon to make decisions. But it is difficult to diagnose because small lesions of the pancreas are sometimes hard to recognize. Here’s one that’s not hard to recognize. Here’s a carcinoma of the head of the pancreas. The major reason that these tumors are not resectable – although some surgeons will do vascular resections as well – but the main reason these are not resectable at many centers is involvement of one of the major vessels. So what the CT scan, a good spiral CT scan, can usually – even without angiography – let you recognize whether the major vessels are involved. Here you see the portal SMV complex free of the tumor, and the SMA. These are the two that are the main ones to worry about. Here’s another carcinoma of the head of the pancreas, involving the portal SMV complex and the SMA and not resectable. More and more centers are willing to do vascular interpositions and resect if the SMV portal complex is involved, or is involved nominally as it is here, and the SMA is clear. Dr. Evans at M.D. Anderson, to whom I am indebted for this particular slide – he uses it as an example of a lesion that he would resect – has done a fairly large series of these and has compared survival and the extent of other involvement, nodal involvement and other indicators of how advanced the disease is, and really there is not – if the surgeon is willing to be aggressive and to resect the portal complex and replace it with a graft – then the outcome is not terribly different than if that complex had not been involved. Here’s a mass in the tail of the pancreas. Most lesions in the tail of pancreas are in minority but most of them become advanced to the point of not being resectable by the time they present. ERCP is also used for diagnosis and supplements the CAT scan. This is the classic ERCP finding in pancreatic cancer, the double duct sign, where you see an occlusion of both the common bile duct and the duct of Wirsung. This almost never occurs except with an expanding mass in the head of the pancreas, which is almost invariably pancreatic cancer.