
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Pancreatic cancer is a leading cause of cancer deaths in both men and women. The American Cancer Society estimated that in 2022, there would be 62,210 new cases of pancreatic cancer and 49,830 deaths from pancreatic cancer (25,970 in men and 23,860 in women).[1] The overall average 5-year survival rate for patients with pancreatic cancer is 11%, though survival is highly dependent on staging.
Approximately 80% of all pancreatic cancers are adenocarcinomas, with only 2% of exocrine pancreatic tumors diagnosed as benign. Formation of pancreatic tumors begins in the pancreas; from there, tumors can spread to nearby lymph nodes and to other areas of the body (liver, peritoneal cavity, intestine, or lungs). Metastasis of cancerous cells can affect organs surrounding the pancreas, including the stomach and the colon.
The image in the slide shows a gross section of a cancerous pancreas measuring 5 × 6 cm that has been resected from the pancreatic body.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The images in the slide are of cytologic samples from fine-needle aspiration (FNA) of pancreatic adenocarcinomas: (A) well-differentiated tumor, (B) moderately differentiated tumor, (C) moderately to poorly differentiated tumor, and (D) poorly differentiated tumor.
Which of the following histologic subtypes of pancreatic cancer is the most common?
- Ductal adenocarcinoma
- Acinar cell carcinoma
- Endocrine tumor
- Cystic neoplasms
- Metastasis to the pancreas
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: A. Ductal adenocarcinoma.
With a prevalence of 80-85%, ductal adenocarcinomas are far more common than all other histologic subtypes of pancreatic cancer. Most ductal adenocarcinomas are tough and gritty gray-white clumps that mainly metastasize in the head of the pancreas.[2] Histologically, most pancreatic adenocarcinomas are moderately to poorly differentiated.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The image portrays a progressive model of pancreatic cancer, from normal epithelium to invasively growing tumor. (PanIN = pancreatic intraepithelial neoplasia.) The horizontal blue bars represent specific mutated genes that aid in the progression of the cancer during specific portions of its development.
Mutations in which of the following genes are commonly found in pancreatic adenocarcinoma?
- K-ras
- P16
- P53
- SMAD4
- All of the above
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: E. All of the above.
Mutations in all of the genes listed in slide 4 are found in pancreatic adenocarcinoma.[3] A general rule for the genetic onset of pancreatic cancer is that multiple combinations of genetic mutations are present in adenocarcinomas. Mutations in K-ras are found in more than 90% of diagnosed pancreatic cancers. Mutations in P16 are seen in 80-95% of diagnosed pancreatic cancers. Alterations in P53 are found in 50-75% of diagnosed pancreatic cancers. Alterations in SMAD4 are seen in approximately 55% of diagnosed pancreatic cancers.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Among newly diagnosed patients with pancreatic cancer, which of the following clinical examination findings is most commonly noted?
- New-onset diabetes mellitus
- Migratory thrombophlebitis (Trousseau syndrome)
- Unexplained pancreatitis
- Malabsorption
- Left supraclavicular lymphadenopathy (Virchow syndrome)
- Hyperbilirubinemia
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: F. Hyperbilirubinemia.
Jaundice and weight loss are the most common symptoms plaguing patients with pancreatic cancer.[4] Elevated levels of bilirubin are caused by the obstruction of the common bile duct, a common symptom of jaundice. The slide shows a small (2-cm) pancreatic tumor producing an obstruction of the common bile duct (cbd) and the pancreatic duct (pd).
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The image in the slide is a computed tomography (CT) scan of a cancerous mass at the head of the pancreas. The gallbladder (gb) is bulging as a result of a biliary obstruction. The superior mesenteric artery (sma) is encompassed by a tumorous mass.
Which of the following imaging techniques does not aid in the diagnosis of pancreatic cancer?
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Endoscopic ultrasonography (EUS)
- Hepatobiliary iminodiacetic acid (HIDA) scan
- Magnetic resonance cholangiopancreatography (MRCP)/magnetic resonance imaging (MRI)
- CT with arterial and venous phase imaging
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: C. Hepatobiliary iminodiacetic acid (HIDA) scan.
The imaging techniques specified in answers A, B, D, and E on slide 8 are all utilized in the diagnosis of pancreatic adenocarcinomas.[4] The algorithm in the slide depicts a step-by-step protocol for evaluating a patient with suspected pancreatic cancer; the details of this step-by-step process may vary from one institution to another. (PET = positron emission tomography; TUS = transcutaneous ultrasonography.)
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The image displays contrast-enhanced CT scans of a tumor-free superior mesenteric artery (SMA) and portal vein.
Which of the following statements regarding resectable pancreatic cancer is not true?
- The process does not involve extrapancreatic disease
- The superior mesenteric vein (SMV) and the portal vein are patent
- There are no distant metastases to surrounding visceral organs
- The 5-year survival rate is 50% for node-negative disease and 30% for node-positive disease
- Both systemic 5-fluorouracil (5-FU) plus leucovorin and low-dose adjuvant gemcitabine are category 1 recommendations, according to National Comprehensive Cancer Network (NCCN) guidelines
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: D. The 5-year survival rate is 50% for node-negative disease and 30% for node-positive disease.
In fact, the 5-year survival rate for patients with node-negative disease is in the range of 30-40%, and that for patients with node-positive disease is roughly 10%.[1,5-7] The slide shows contrast-enhanced CT scans of a patient with tumor invasion of the celiac trunk and the portal vein confluence (arrows).
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The CT scan in the slide shows a pancreatic tumor abutting more than 180o of the SMA, a position that renders the cancer unresectable.
Which of the following statements regarding locally advanced disease in a patient with unresectable pancreatic cancer is not true?[8]
- This stage is characterized by extensive involvement of the portal vein, the SMV, the celiac axis, or the SMA
- If the patient's performance status is good, FOLFIRINOX (folinic acid, fluorouracil, irinotecan, oxaliplatin) or gemcitabine plus albumin-bound paclitaxel can be considered
- Local radiation therapy can be an option
- For a patient whose performance status is poor, gemcitabine therapy alone can be considered vs palliative care
- Conversion from unresectable to resectable may occur with neoadjuvant therapy
- The general overall prognosis for this stage is a life expectancy of 12-24 months
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Image courtesy of National Library of Medicine.
Answer: F. The general overall prognosis for this stage is a life expectancy of 12-24 months.
The correct time frame is 8-12 months. The slide displays axial and coronal dose-painted intensity-modulated radiation therapy (DP-IMRT) plans for treatment of a pancreatic cancerous mass.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The CT scan in the slide shows a solid pseudopapillary tumor of the pancreas with metastases to the right liver.
Which of the following statements regarding metastatic pancreatic cancer is/are true?[8]
- Metastasis to the liver and peritoneum is common, and metastatic disease sometimes can disseminate as far as the lungs
- Systemic chemotherapy can lengthen overall survival from 3-6 months to 10-11 months
- Genomic sequencing can be considered if a patient progresses on standard chemotherapy
- Erlotinib has been shown to add a modest (2-week) overall survival benefit to gemcitabine therapy
- All of the statements above are true
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: E. All of the statements above are true.
The image in the slide shows a liver with multiple metastatic lesions from a primary pancreatic adenocarcinoma.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The image in the slide shows immunohistochemical staining for CA 19.9 in the vicinity of the pancreatic adenocarcinoma.
Which of the following is not included in posttreatment surveillance of pancreatic cancer patients?
- Upper gastrointestinal (GI) endoscopy every 3-6 months for 2 years, then annually
- History and physical examination every 3-6 months for 2 years, then annually
- CT every 3-6 months for 2 years, then annually
- CA 19.9 every 3-6 months for 2 years, then annually
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: A. Upper gastrointestinal (GI) endoscopy every 3-6 months for 2 years, then annually.
The measures listed in answers B, C, and D on slide 16 are done every 3-6 months for 2 years after treatment of pancreatic cancer and annually thereafter; upper GI endoscopy on this schedule is not indicated.
The EUS image in the slide shows a pancreatic tumor at the head of the pancreas that is blocking the common bile duct but not the portal vein or the SMV.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
The micrograph in the slide demonstrates a pancreatic neuroendocrine tumor (PNET) with the help of hematoxylin and eosin staining.
Which of the following statements regarding PNETs is not true?
- Treatment is indicated for all asymptomatic and symptomatic PNETs to decrease the disease burden
- Sunitinib and everolimus have both been shown to be efficacious against PNETs
- PNETs can be divided into functional and nonfunctional types
- Chemoembolization can be used to reduce tumor volume in cases of liver metastasis
- Somatostatin-receptor PET (SSTR-PET) is the imaging modality of choice for diagnosing PNETs
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Answer: A. Treatment is indicated for all asymptomatic and symptomatic PNETs to decrease the disease burden.
Treatment is indicated for all symptomatic PNETs and asymptomatic PNETs larger than 2 cm.[9] The photograph in the slide (left) shows a functional PNET at an early stage (arrow), but pinpointing the main tumor proves difficult. The CT scan (right) shows a nonfunctional PNET at the tail of the pancreas (right arrow); an associated metastasis in the liver is visible (left arrow). SSTR-PET is the imaging modality of choice for diagnosing PNETs.[9]
Comments