Updated 1 November 2005

Clinical Presentation(3)

The majority of patients present with jaundice as a result of the tumour causing obstruction of the common bile duct. This is often accompanied by any of the following signs and symptoms: abdominal pain, dark urine, light stools, weight loss, pruritus, weakness, and anorexia. A minority of patients present only with epigastric or central back pain. About 10% have associated new-onset diabetes mellitus. Acute pancreatitis not associated with alcohol abuse or gallstones should be investigated for a possible malignancy. Laboratory tests in patients presenting with jaundice show elevated serum bilirubin, alkaline phosphatase, and ã-glutamyl transpeptidase, with mild elevations of transaminases. The chronic nature of the disease may result in normochromic anemia and mild hypoalbuminemia. Patients with significant hyperbilirubinemia have malabsorption of fat-soluble vitamins which results in prolongation of prothrombin time.

Diagnostic Imaging

Ultrasonography and computed tomography (CT) remain the usual means by which most pancreatic tumours are detected. Occasionally, additional information may be obtained from magnetic resonance imaging (MRI). Endoscopic retrograde cholangiopancreatography (ERCP) is often required to address biliary obstruction but not routinely used for diagnostic purposes. Endoscopic ultrasound (EUS) may be available in the future as a more sensitive method of diagnosis.

Diagnostic Pathology

Pancreatic tumours can be of exocrine and endocrine origin. Endocrine tumours are discussed in Section 12: Neuroendocrine. Exocrine tumours can be further described as either cystic or solid. The vast majority (90%) of neoplasms arising from the pancreas are solid infiltrating ductal adenocarcinomas.

In patients with potentially resectable pancreas cancer, biopsies are generally not indicated. Patients should be referred to a hepatobiliary surgeon who may choose to do a laparoscopy to biopsy and stage the patient. Occult peritoneal or liver metastases may be found in 20% to 40% of patients deemed resectable by imaging.(8) For patients with metastatic disease, unresectable tumours, or those who are not surgical candidates, a biopsy can be done percutaneously. It is not uncommon that fine needle aspirations prove to be non-diagnostic as there is often a large desmoplastic reaction associated with these tumours. A core biopsy can be considered if it can be safely done. There have been reports of tumour seeding along the needle tract; however, a tissue diagnosis should be obtained whenever possible to ensure proper management. Patients who may participate in clinical trials are generally required to have a histologic diagnosis.

Cystic tumours of the pancreas include mucinous cystic neoplasms, intraductal papillary mucinous neoplasms (IPMNs), serous cystic neoplasms, and solid-pseudopapillary neoplasms. Surgical management is the treatment of choice and usually results in cure.(9-11)