pancreatic%20cancer
PANCREATIC CANCER
Pancreatic cancer is malignancy arising from the pancreas.
It is the 13th most common cancer in the world, 10th most common in the United States, and 4th leading cause of cancer-related deaths in the United Stated and Europe.
Exocrine tumors account for 95% of malignant pancreatic disease.
It is more common in women.
The median age of occurrence is at 71 years old.

Diagnosis

Screening

American Cancer of the Pancreas Screening (CAPS) Consortium criteria for high-risk individuals to be considered for screening:

  • Peutz-Jeghers syndrome patients
  • Familial breast/ovarian cancer patients w/ at least 1 affected 1st- or 2nd-degree relative w/ pancreatic cancer
  • Relatives of patients w/ familial pancreatic cancer w/ at least 1 affected 1st-degree relative

The Fourth International Symposium of Inherited Diseases of the Pancreas criteria for high-risk individuals to be considered for screening:

  • Patients w/ >10-fold risk for pancreatic cancer (FAMMM, hereditary pancreatitis, Peutz-Jeghers syndrome, >3 1st-degree relatives w/ pancreatic cancer)
  • Patients w/ >3 1st-, 2nd-or 3rd-degree relatives diagnosed w/ pancreatic cancer, w/ >1 being a 1st-degree relative
  • Known BRCA1, BRCA2 & PALB2 mutation carriers who have >1 1st- or 2nd-degree relative w/ pancreatic cancer

Recommended age to start screening:

  • 45-50 years of age
  • 15 years before the earliest relative’s cancer onset
  • 30 years of age for patients w/ Peutz-Jeghers syndrome

Imaging

Imaging Procedures:

Computed Tomography (CT)

  • Preferred imaging study for the diagnosis and initial staging of pancreatic cancer
  • Multiphase pancreatic protocol CT w/ IV contrast in ≤3 mm thin cuts recommended
    • Noncontrast phase, contrast-enhanced arterial, pancreatic parenchymal, & portal venous phases should be included
  • For detection of pancreatic cancer: 74-98% accurate, 77-97% sensitive, 85-100% specific
  • For prediction of vascular invasion: 55-97% sensitive, 91-100% specific
  • For predicting resectability: 76-92% sensitive, 82-100% specific
  • Chest CT may be used to assess pulmonary metastasis before surgery

Computed Tomography - Positron Emission Tomography (CT-PET)

  • Sensitivity for metastatic pancreatic cancer increases to 87% when combined w/ CT as compared to standard CT alone (57%)

Magnetic Resonance Imaging (MRI)

  • Multiphase pancreatic protocol MRI is recommended as an alternative for the detection of smaller lesions when CT is contraindicated
  • Effectively differentiates cancer & pancreatitis
  • Magnetic resonance cholangiopancreatography (MRCP)
    • Provides information on the patency of biliary & pancreatic ducts
    • Identifies vascular invasion

Endoscopic Ultrasound (EUS)

  • Used to identify nodal/vasculature involvement, suspected small lesions (<2 cm) not seen in CT/MRI, tumor size, & stage & resectability of disease
  • 86-96% accurate, 85-100% sensitive, 98% specific for pancreatic cancer
  • Preferred over CT/MRI for the detection of small tumors & differentiating cystic from solid lesions
  • Complementary to CT/MRI for staging purposes
  • Allows performance of fine-needle aspiration biopsy (FNAB) to confirm the presence of pancreatic cancer

Endoscopic Retrograde Cholangiopancreatography (ERCP)

  • Detects abnormalities/tumors in the pancreatic & bile ducts
  • Useful in identifying strictures w/in the ducts not diagnosed in other imaging modalities
  • May also be used to place stents for decompression of biliary/pancreatic obstructions prior to surgery or chemotherapy

Laparoscopy

  • May be used to identify the stage of pancreatic cancer to rule out previous staging by imaging techniques
  • May detect peritoneal, capsular, or serosal implants & hepatic metastases

Laboratory Tests

Biopsy

  • EUS w/ fine-needle aspiration (FNA) is the recommended procedure for histologic confirmation of pancreatic cancer tumors
    • Preferred for its lower chances of peritoneal seeding, higher diagnostic yield, & confirmation of disease stage
    • 92% accurate, 84% accurate to refute or confirm negative CT-guided biopsy results
  • CT-guided FNA is an alternative when EUS is not available
    • May also be used to biopsy possible metastases
  • ERCP brushings are also an alternative for patients w/o mass in imaging but w/ biliary stricture
  • Repeat biopsy is recommended before neoadjuvant therapy, prior to surgery, after stent placement, or in cases when previous biopsy is doubtful or inconclusive

Tumor Markers
  • Eg CA 19-9, carcinoembryonic antigen (CEA)
  • May be used to predict prognosis, recurrence rates, & outcome marker; also used to diagnose the cause of jaundice
  • Use for screening is not routinely done because of lack of specificity for pancreatic cancer
  • CA 19-9 is the most useful tumor marker & is recommended prior to surgery & postoperatively to determine status of disease & treatment response
    • An abrupt drop in CA 19-9 levels postoperatively may indicate treatment success & good prognosis
    • CA 19-9 levels of ≥180 U/mL is associated w/ worse median survival rate (9 mth)
    • CA 19-9 levels of ≤180 U/mL is associated w/ better median survival rate (21 mth)

Staging

Tumor-Node-Metastasis System for PC

  • Developed by the American Joint Committee on Cancer (AJCC) & the Union for International Cancer Control (UICC)
T categories
TX The main tumor cannot be assessed
T0 No evidence of a primary tumor
Tis Carcinoma in situ (very few tumors are found at this stage)
T1 The cancer has not spread beyond the pancreas and is <2 cm (~0.75 inch) across
T2 The cancer has not spread beyond the pancreas but is >2 cm across
T3 The cancer has spread from the pancreas to surrounding tissues near the pancreas but not to blood vessels
T4 The cancer has extended further beyond the pancreas into nearby large blood vessels
N categories
NX Regional lymph nodes cannot be assessed
N0 Regional lymph nodes (lymph nodes near the pancreas) are not involved
N1 Cancer has spread to regional lymph nodes
M categories
MX Spread to distant organs cannot be assessed
M0 The cancer has not spread to distant lymph nodes or to distant organs
M1 Distant metastasis is present
Stage Grouping for Pancreatic Cancer
Stage 0 (Tis, N0, M0) The tumor is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside the pancreas.
Stage IA (T1, N0, M0) The tumor is confined to the pancreas and is <2 cm in size. It has not spread to nearby lymph nodes or distant sites.
Stage IB (T2, N0, M0) The tumor is confined to the pancreas and is >2 cm in size. It has not spread to nearby lymph nodes or distant sites.
Stage IIA (T3, N0, M0) The tumor is growing outside the pancreas but not into large blood vessels. It has not spread to nearby lymph nodes or distant sites.
Stage IIB (T1–3, N1, M0) The tumor is either confined to the pancreas or growing outside the pancreas but not into nearby large blood vessels. It has spread to nearby lymph nodes but not distant sites.
Stage III (T4, any N, M0) The tumor is growing outside the pancreas into nearby large blood vessels. It may or may not have spread to nearby lymph nodes. It has not spread to distant sites.
Stage IV (any T, any N, M1) The cancer has spread to distant sites.
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