Chapter 089. Pancreatic Cancer (Part 3)

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Carcinoma of the pancreas. A. Sonogram showing pancreatic carcinoma (P), dilated intrahepatic bile ducts (d), dilated portal vein (pv), and inferior vena cava (IVC). B. Computed tomography scan showing pancreatic carcinoma (dark arrows). C. Endoscopic retrograde showing abrupt c utoff of the duct of Wirsung (arrow). D. Magnetic resonance cholangiopancreatography showing obstruction (Obs) in the pancreatic duct (PD). The gallbladder (GB), hepatic duct (HD), and common bile duct (CBD) are labeled. Tissue Diagnosis and Cytology Patients with disease that is potentially curable by surgery, and in whom a highly suspicious lesion is seen on imaging, are often taken directly to...

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Chapter 089. Pancreatic Cancer (Part 3) Carcinoma of the pancreas. A. Sonogram showing pancreatic carcinoma (P), dilated intrahepatic bile ducts (d), dilated portal vein (pv), and inferior vena cava (IVC). B. Computed tomography scan showing pancreatic carcinoma (dark arrows). C. Endoscopic retrograde showing abrupt c utoff of the duct of Wirsung (arrow). D. Magnetic resonance cholangiopancreatography showing obstruction (Obs) in the pancreatic duct (PD). The gallbladder (GB), hepatic duct (HD), and common bile duct (CBD) are labeled. Tissue Diagnosis and Cytology Patients with disease that is potentially curable by surgery, and in whom a highly suspicious lesion is seen on imaging, are often taken directly to surgery without prior tissue confirmation of cancer. This is because of theoretical concerns that a percutaneous fine-needle aspiration may result in dissemination of cancer intraperitoneally or along the track of the biopsy needle. In addition, negative
cytology may not be sufficient evidence to avoid surgery, particularly with small lesions. EUS-guided fine-needle aspiration is increasingly being used, even in patients with potentially resectable disease, as there is less risk of intraperitoneal spread of cancer. Other methods of obtaining specimens for cytological analysis include sampling of pancreatic juices or brushings of ductal lesions obtained by ERCP. Serum Markers The most widely used serum marker in pancreatic cancer is cancer- associated antigen 19-9 (CA 19-9). It has a reported sensitivity and specificity of about 80–90%, and is suggestive, rather than confirmatory, of the diagnosis of pancreatic cancer. Serum levels of CA 19-9 can be elevated in patients with jaundice without pancreatic cancer present. The level of CA 19-9 may have prognostic implications, with very high levels sometimes found in patients with inoperable disease. In advanced disease, patients treated with chemotherapy who had high pretreatment levels of CA 19-9 have also been found to have a worse survival, whereas those patients whose levels of marker fell with treatment had a better outcome. In patients with cancers with elevated CA 19-9, serial evaluation of this marker is useful for monitoring responses to treatment. In patients with completely resected tumors, follow-up with CA 19-9 is useful for detecting recurrence.
Staging In pancreatic cancer, which has a poor prognosis, the value of detailed clinical staging is limited. The most clinically relevant distinction to make is between patients with disease that may be resected with curative intent, and those with advanced disease in whom treatment is palliative (Table 89-1). Table 89-1 Staging of Pancreatic Carcinoma Stage TNM Staginga Grouping Localized I T1–2 N0 M0 resectable II T3 N0 M0 or T1–3 N1 M0 Locally advanced III T4 N(any) M0 Metastatic IV T(any) N(any) M1
a TNM, tumor, nodes, metastasis. Note: T1, tumor limited to pancreas, ≤2 cm; T2, tumor limited to pancreas, >2 cm; T3, tumor extends beyond the pancreas but without involvement of celiac axis or superior mesenteric artery; T4, tumor involves celiac axis or the superior mesenteric artery (unresectable primary tumor); N0, no regional lymph node metastasis (regional lymph nodes are the peripancreatic lymph nodes, including the lymph nodes along the hepatic artery, celiac axis and pyloric/splenic regions); N1, regional lymph node metastasis; M0, no distal metastasis; M1, distal metastasis. Source: Modified from Greene, Page; with permission. Surveillance in High-Risk Individuals Routine screening for pancreatic cancer is not recommended due to a high false-positive rate of the available tests. However, screening may be reasonable in certain high-risk individuals, such as those with strong family histories, although the optimal timing, frequency, and method of screening is unknown. One recommendation is to commence screening at the age of 35 in patients with hereditary pancreatitis, or 10 years before the age of the youngest diagnosis of pancreatic cancer in those with a significant family history using spiral CT, followed by EUS when CT results have been indeterminate.