Diagnosis and Management of Pancreatic Ductal Adenocarcinoma

Clinical Features

Persistent back pain, marked and rapid weight loss, abdominal mass, ascites, and supraclavicular lymphadenopathy usually indicate an incurable situation 1
Adult-onset diabetes without predisposing features or family history may be an early indicator of pancreatic cancer 1
Unexplained episodes of acute pancreatitis should prompt investigation for underlying pancreatic cancer 1

Ultrasound of the liver, bile duct, and pancreas should be performed without delay when clinical presentation suggests pancreatic cancer 1
Blood counts and liver enzymes should be included in the initial workup 2
Pancreatic protocol CT scan or MRI are the preferred imaging studies for diagnosis and staging 1
When malignancy is suspected from clinical symptoms and/or ultrasound findings, selective use of CT, ERCP, and/or MR (including MRCP and occasionally MRA) will accurately delineate tumor size, infiltration, and metastatic disease 1
Endosonography (EUS) may be appropriate in selected cases for better visualization of the pancreas and to obtain tissue samples 1

Pathological diagnosis should be made according to the World Health Organization classification from a biopsy or fine needle aspiration 2
Ductal adenocarcinomas constitute 95% of pancreatic epithelial tumors 2
Attempts should be made to obtain tissue diagnosis during investigative endoscopic procedures 1
Failure to obtain histological confirmation does not exclude the presence of a tumor when clinical suspicion is high 1

Staging includes complete history and physical examination, blood counts, liver enzymes, chest X-ray, abdominal imaging, and possibly endosonography 2
TNM staging system is used, though it does not well reflect tumor resectability 2
Evaluation of resectability often requires surgery, preferably staging laparoscopy to exclude clinically occult intra-abdominal and lymph node metastases 2
Resectable tumors must show no evidence of extra-pancreatic disease, direct tumor extension to the celiac axis and superior mesenteric artery, or non-obstructive invasion of the superior mesenteric-portal vein confluence 2
Less than 20% of patients have resectable disease at diagnosis 2, 3

Complete surgical resection is the only potentially curative treatment available 2
Five-year overall survival after resection is only 10-20% 2
Long-term survival in lymph node positive (N+) tumors is rare 2
Gemcitabine has been associated with a small survival benefit compared with bolus 5-fluorouracil 2
Optimal symptomatic treatment has a prime role in management 2
Stenting or bypass surgery may be required for obstructive jaundice or gastric outlet obstruction 2

Due to the limited effectiveness of treatments, follow-up after complete resection should be restricted to history and physical examination 2
Response evaluation should be symptom-driven rather than based on radiographic tests alone 2

Patients at increased inherited risk of pancreatic cancer should be referred to specialist centers offering genetic counseling and appropriate testing 1
Secondary screening for pancreatic cancer in high-risk cases should be carried out as part of an investigational program coordinated through specialist centers 1
Examination and biopsy of the periampullary region is important in patients with longstanding familial adenomatous polyposis 1
Continued health education to reduce tobacco consumption should lower the risk of developing pancreatic carcinoma 1