Exocrine Pancreatic Cancer: Clinical Presentation, Diagnosis, and Treatment

by Richard Mitchell, MD, PhD

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    00:01 So the clinical presentation.

    00:03 If the cancer is in the pancreatic head, as I just said, and that's indicated there as that kind of brown stellate thing near the pancreatic duct.

    00:12 And near the common bile duct, you get painless, obstructive jaundice.

    00:16 It will be associated with elevated bilirubins with pruritus, itchiness and very light-colored stools, because you're not able to get bile into the GI tract to give the typical brown color to stool.

    00:27 You may also see that the gallbladder is distended and enlarged because it can't dump its contents.

    00:33 That will be the so called couvoisier sign.

    00:35 There is an enlarged, palpable nontender gallbladder.

    00:40 That's if you're lucky and unlucky is a relative term.

    00:44 But in that case, you may pick up relatively small tumors very early in their course.

    00:49 And it gives you the best chance of potentially doing a curative resection.

    00:54 If on the other hand, the cancer is in the body and the tail, it's usually discovered only very late.

    01:00 The pancreas can be remarkably silent in terms of masses and lesions.

    01:05 Eventually, with extension of the tumor or metastatic disease, you may develop severe pain in the upper abdomen.

    01:11 It may radiate to the back frequently with adenocarcinomas has in a variety of locations but very commonly in the pancreas, you'll see a hypercoagulable state, a so called Trousseau syndrome with evanescent thrombosis throughout the body.

    01:30 So in addition to potentially having this pain, late and hypercoagulable state with significant tumor burden.

    01:39 You can also eventually with metastatic disease involving the porta hepatis, the lymph nodes that sit near the head of the pancreas.

    01:48 You can end up with portal hypertension as a result of the portal hypertension and the occlusion of the vasculature at that point, You may develop esophageal and gastric varices.

    02:00 With very advanced disease there's typically a very profound and rapid downhill course.

    02:06 With weight loss and anorexia associated with a tumor cachetic state.

    02:11 Patients may present with brand new diabetes mellitus as they lose a lot of their islet mass due to the expansion of the tumor within the pancreas.

    02:21 Clearly they're not making the appropriate enzymes that would be responsible for breaking down various ingested proteins, fats, sugars, so there'll be malabsorption with associated diarrhea.

    02:36 Any intra abdominal tumor, gastric cancer, esophageal cancer, and pancreatic cancer is no exception, you may get a Virchow's node that's at the point where the thoracic duct dumps into the left subclavian vein.

    02:49 And you get may get a prominent node at that point over the left clavicle.

    02:54 And then you may have a retrograde tumor that goes into the umbilicus.

    02:59 And around the belly button, the umbilicus, you may have a so called Sister Mary Joseph's nodule.

    03:06 How do we make the diagnosis? Well, it's mainly the biopsy.

    03:10 This is where your pathologist your friendly neighborhood pathologist comes in handy.

    03:14 On the left hand side is the normal structure of pancreas.

    03:19 So most of the cells that are present on here represent the acinar cells that are responsible for the exocrine pancreas, the pancreas secretions.

    03:27 That one cleared out nodular area, kind of right in the middle of the picture is an islet.

    03:34 So a pancreatic islet that's going to be responsible for making things like insulin and glucagon.

    03:39 And then finally, you see the duct indicated there.

    03:43 And that is lined by a cuboidal to low columnar epithelium.

    03:48 And that's going to be the major source, those cells are the major source of pancreatic exocrine carcinomas.

    03:56 On the right hand side is what this evil, evil tumor looks like.

    04:01 And there are glands, kind of ill defined glands, with very atypical cells surrounded by a very dense, fibrous stroma.

    04:11 And that's that desmoplastic response.

    04:15 Once we made the diagnosis, what do we do about it? So, surgical resection is really our only hope in this particular case.

    04:26 In the event that there has been no invasion of vessels, there has been no apparent metastatic disease, which is a minority of the patients.

    04:33 We will often give neoadjuvant therapy upfront chemotherapy, do our resection and then do adjuvant chemotherapy afterwards.

    04:42 And even in the very best of circumstances, small surgically resectable tumor, no invasion metastatic disease, the median survival is less than 2 years.

    04:53 So I said this is a bad tumor.

    04:54 I'm not telling you stories.

    04:57 If there's locally advanced disease, you know, the long term kind of outlook is even worse.

    05:05 So we will definitely do chemotherapy before and after any potential surgery.

    05:11 And the median survival is less than a year.

    05:14 And with distant metastatic disease, we're talking the same thing.

    05:17 We can give systemic chemotherapy but most of our therapies just do not work.

    05:22 The overall five-year survival all comers and if you talk, you know, look at the various percentages of minimal disease and locally advanced disease etc.

    05:31 The overall five year survival all comers with pancreatic cancer is 10% or less.

    05:39 The typical classic surgical procedure that we can try to do is called a Whipple procedure.

    05:44 So a pancreaticoduodenectomy.

    05:47 And what we're going to do what's shown on the left hand side, we're going to cut out the tumor at the head of the pancreas.

    05:52 And we are going to reroute the bile ducts into a loop of the duodenum.

    05:59 So we can get normal biliary drainage.

    06:02 We're not going to get rid of all of the pancreas, we're going to have the pancreas and its duct connected up to that portion of duodenum.

    06:09 And then we're going to do essentially gastric bypass surgery, dumping post antrum into kind of a secondary or tertiary loop of the duodenum.

    06:19 And we cut out the head of the pancreas, we cut out the gallbladder.

    06:23 Frequently, we may also remove the spleen, the lymph nodes, and that portion of the loop of the duodenum.

    06:29 You see there in gray on the left hand side.

    06:32 That's a Whipple procedure.

    06:33 It's a pretty amazing and very invasive and very destructive kind of surgery.

    06:41 And, as you saw, even with a Whipple procedure, the outcome is not a happy one in most cases.

    06:49 So if everything is node negative and it's all perfect, 5-year survival is about 30%.

    06:55 If there is a node that is found to be positive at the time of surgery, it goes less than 10%.

    07:00 And remember, I said all comers survival at five years is less than 10%.

    07:06 And with that, sorry, it's kind of a sad, depressing tale.

    07:10 But for those of you who want to go into oncology, those who want to find an important kind of way to help your patients, figuring out a better way to treat pancreatic cancer will go a long way.

    07:22 We do not do a good job right now.

    07:24 And with that, I'll close.

    About the Lecture

    The lecture Exocrine Pancreatic Cancer: Clinical Presentation, Diagnosis, and Treatment by Richard Mitchell, MD, PhD is from the course Small and Large Intestines Disorders.

    Included Quiz Questions

    1. Painless obstructive jaundice
    2. Painful emesis
    3. Painless emesis
    4. Painful obstructive jaundice
    5. Painful nonobstructive jaundice
    1. 15%
    2. 55%
    3. 75%
    4. 5%
    5. 45%

    Author of lecture Exocrine Pancreatic Cancer: Clinical Presentation, Diagnosis, and Treatment

     Richard Mitchell, MD, PhD

    Richard Mitchell, MD, PhD

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