Please confirm that you would like to log out of Medscape.
If you log out, you will be required to enter your username and password the next time you visit.
Log outCancel
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022
| Contributor Information
Swipe to advance
Image courtesy of Medscape.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.
Image courtesy of Medscape.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of Wikimedia Commons.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.
Image adapted from National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image adapted from National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.
Image courtesy of Wikimedia Commons.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of Medscape.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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).
Image courtesy of Medscape.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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?
Magnetic resonance cholangiopancreatography (MRCP)/magnetic resonance imaging (MRI)
CT with arterial and venous phase imaging
Image courtesy of Medscape.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.)
Image courtesy of National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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).
Image courtesy of National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.
Image courtesy of Wikimedia Commons.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of Wikimedia Commons.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.
Image courtesy of National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of Medscape.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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.
Image courtesy of Wikimedia Commons.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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
Image courtesy of National Library of Medicine.
Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook
Roman Leonid Kleynberg, MD; Gennadiy (Henry) Guralnik | April 5, 2022 | Contributor Information
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]
Commenting is limited to medical professionals. To comment please Log-in.
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Close
Contributor Information
Authors
Roman Leonid Kleynberg, MD
University of California, Irvine Medical Center
Chao Family Comprehensive Cancer Center
Department of Hematology/Oncology
Orange, CA
Disclosure: Roman Leonid Kleynberg, MD, has disclosed no relevant financial relationships.
Gennadiy (Henry) Guralnik
Department of Neuroscience
University of California, Los Angeles
Disclosure: Gennadiy (Henry) Guralnik has disclosed no relevant financial relationships.
Reviewer
Ali Ahmad, MD
Surgical Oncologist and Clinical Assistant Professor of Surgery
University of Kansas School of Medicine-Wichita
Disclosure: Ali Ahmad, MD, has disclosed no relevant financial relationships.
Close
References
Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7-33. PMID: 35020204
Wilentz RE, Iacobuzio-Donahue CA, Argani P, et al. Loss of expression of Dpc4 in pancreatic intraepithelial neoplasia: evidence that DPC4 inactivation occurs late in neoplastic progression. Cancer Res. 2000 Apr 1;60(7):2002-6. PMID: 10766191
Porta M, Fabregat X, Malats N, et al. Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. Clin Transl Oncol. 2005 Jun;7(5):189-97. PMID: 15960930
Gnerlich JL, Luka SR, Deshpande AD, et al. Microscopic margins and patterns of treatment failure in resected pancreatic adenocarcinoma. Arch Surg. 2012 Aug;147(8):753-60. PMID: 22911074
Iacobuzio-Donahue CA, Fu B, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol. 2009 Apr 10;27(11):1806-13. PMID: 19273710
Hishinuma S, Ogata Y, Tomikawa M, Ozawa I, Hirabayashi K, Igarashi S. Patterns of recurrence after curative resection of pancreatic cancer, based on autopsy findings. J Gastrointest Surg. 2006 Apr;10(4):511-8. PMID: 16627216
Howe JR, Merchant NB, Conrad C, et al. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas. 2020;49(1):1-33. PMID: 31856076
Please do not use this form to submit personal or patient medical information or to report adverse drug events. You are encouraged to report adverse drug event information to the FDA.
Comments