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__NOTOC__
{{Pancreatic cancer}}
{{Pancreatic cancer}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; {{AE}} {{Cherry}}


==Overview==
==Overview==
During physical examination, a clinician may find characteristics of pancreatic cancer in a patient. These include: pain,. weight loss, or jaundice.
[[Patient|Patients]] with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with [[Medical sign|signs]] of [[malnutrition]]. Patients mostly present with [[Palpation|palpable]] [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatospleenomegaly]] and [[Medical sign|signs]] of [[metastasis]] in advanced stages. These [[Medical sign|signs]] of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), [[Palpation|palpable]] periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area.  
==Physical Examination==


==Physical Examination==
*Physical examination of patients with [[pancreatic cancer]] is usually remarkable for: [[epigastric]] [[tenderness]], [[jaundice]], and [[Palpation|palpable]] intra abdominal mass.
Most patients with pancreatic cancer experience pain, weight loss, or [[jaundice]].<ref name="pmid1589710">{{cite journal |author=Bakkevold KE, Arnesjø B, Kambestad B |title=Carcinoma of the pancreas and papilla of Vater: presenting symptoms, signs, and diagnosis related to stage and tumour site. A prospective multicentre trial in 472 patients. Norwegian Pancreatic Cancer Trial |journal=Scand. J. Gastroenterol. |volume=27 |issue=4 |pages=317–25 |year=1992 |pmid=1589710|doi=10.3109/00365529209000081 }}</ref>
*The presence of left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') on physical examination is diagnostic of [[metastasis]].
*The presence of [[ascites]] and a palpable, non tender [[Gallbladder|gall bladder]] on physical examination is a common finding in [[pancreatic cancer]] patients.


Pain is present in 80 to 85 percent of patients with locally advanced or advanced metastic disease. The pain is usually felt in the upper abdomen as a dull ache that radiates straight through to the back. It may be intermittent and made worse by eating.
===Appearance of the Patient===
Weight loss can be profound; it can be associated with [[anorexia]], early [[satiety]], [[diarrhea]], or [[steatorrhea]].
Patients with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with signs of [[malnutrition]]. Patients mostly present with palpable [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatosplenomegaly]] and signs of [[metastasis]] in advanced stages. These signs of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area.
[[Jaundice]] is often accompanied by [[Itch|pruritus]] and dark urine. Painful jaundice is present in approximately one-half of patients with locally unresectable disease, while painless jaundice is present in approximately one-half of patients with a potentially resectable and curable lesion.


The initial presentation varies according to location of the cancer. Malignancies in the pancreatic body or tail usually present with pain and weight loss, while those in the head of the gland typically present with steatorrhea, weight loss, and jaundice. The recent onset of atypical diabetes mellitus, a history of recent but unexplained [[thrombophlebitis]] ([[Trousseau's sign]]), or a previous attack of [[pancreatitis]] are sometimes noted.
===Vital Signs===


[[Courvoisier's law|Courvoisier sign]] defines the presence of jaundice and a painlessly distended [[gallbladder]] as strongly indicative of pancreatic cancer, and may be used to distinguish pancreatic cancer from [[gallstone]]s.
*Regular [[pulse]]
*Normal [[blood pressure]]
*Normal body temperature


Tiredness, irritability and difficulty eating due to pain also exist. Pancreatic cancer is usually discovered during the course of the evaluation of aforementioned symptoms.
===Skin===
Skin findings are as follows: <ref name="pmid4005804">{{cite journal |vauthors=Kalser MH, Barkin J, MacIntyre JM |title=Pancreatic cancer. Assessment of prognosis by clinical presentation |journal=Cancer |volume=56 |issue=2 |pages=397–402 |year=1985 |pmid=4005804 |doi= |url=}}</ref><ref name="pmid15522652">{{cite journal |vauthors=Khorana AA, Fine RL |title=Pancreatic cancer and thromboembolic disease |journal=Lancet Oncol. |volume=5 |issue=11 |pages=655–63 |year=2004 |pmid=15522652 |doi=10.1016/S1470-2045(04)01606-7 |url=}}</ref><ref name="pmid3958764">{{cite journal |vauthors=Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G |title=Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center |journal=J. Clin. Oncol. |volume=4 |issue=4 |pages=509–14 |year=1986 |pmid=3958764 |doi=10.1200/JCO.1986.4.4.509 |url=}}</ref><ref name="pmid1330387">{{cite journal |vauthors=Ostlere LS, Branfoot AC, Staughton RC |title=Cicatricial pemphigoid and carcinoma of the pancreas |journal=Clin. Exp. Dermatol. |volume=17 |issue=1 |pages=67–8 |year=1992 |pmid=1330387 |doi= |url=}}</ref><ref name="pmid3164230">{{cite journal |vauthors=Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T |title=Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients |journal=Cancer |volume=62 |issue=1 |pages=135–41 |year=1988 |pmid=3164230 |doi= |url=}}</ref>
*[[Jaundice]]: Yellowish discoloration of [[skin]], [[sclera]]
**Associated with [[Palpation|palpable]], non-tender and distended [[gallbladder]] at the right costal margin ([[Courvoisier's law|Courvoisier's sign]])<ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |year=2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref> 
**[[Excoriation|Excoriations]] of the [[skin]] from unrelenting [[Itch|pruritus]] 
**Darkening of the [[urine]] 
** [[Acholic stools|Acholic]] [[Human feces|stools]] 
* [[Pallor]] ±
* [[Skin]] manifestations may include:
** [[Bullous pemphigoid]]
** [[Mucous membrane pemphigoid|Cicatricial pemphigoid]]
** [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
** [[Panniculitis|Pancreatic panniculitis]]:
*** Associated with [[Acinar cell|acinar cell variant]] of [[pancreatic cancer]]
*** Located mostly on the legs
*** Appears as an [[Erythema|erythematous]] [[Subcutaneous tissue|subcutaneous]] area of [[Nodule (medicine)|nodular]] [[fat necrosis]]
The following picture depicts [[bullous pemphigoid]] [[Lesion|lesions]] in a [[patient]]:


[[Liver function test]]s can show a combination of results indicative of bile duct obstruction (raised [[conjugated bilirubin]], [[Gamma glutamyl transpeptidase|γ-glutamyl transpeptidase]] and [[alkaline phosphatase]] levels). [[CA19-9]] (carbohydrate antigen 19.9) is a [[tumor marker]] that is frequently elevated in pancreatic cancer.  However, it lacks sensitivity and specificity. When a cutoff above 37 U/mL is used, this marker has a sensitivity of 77% and specificity of 87% in discerning benign from malignant disease. CA 19-9 might be normal early in the course, and could be elevated due to benign causes of biliary obstruction.<ref>{{cite book |author=Frank J. Domino M.D.etc. |title=5 minutes clinical suite version 3 | year=2007 | publisher=Lippincott Williams & Wilkins | location=Philadelphia, PA}}</ref>
[[Image:Pancreatic_cancer_-_Bullous_pemphgoid.jpg|thumb|350px|center|CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781]]


Imaging studies, such as [[computed tomography]] (CT scan) can be used to identify the location of the cancer. [[Endoscopic ultrasound]] (EUS) is another procedure that can help visualize the location and can serve to guide a percutaneous needle biopsy, which is necessary to establish a definitive diagnosis.<ref name=ACP>Philip, Philip Agop. "Pancreatic Cancer." ''ACP PIER & AHFX DI Essentials.'' American College of Physicians. 4 Apr 2008. Accessed 7 Apr 2009.</ref>
{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}


Recent research indicates that in pancreatic cancer [[Malignant|malignancies]], the tumor contains markedly higher levels of certain [[microRNA]]s (miRNA) than does the patient's [[benign]] pancreatic tissue or that found in other healthy pancreases. This paves the way for two possibilities:
===Neck===
*Signs of [[Metastasis|metastatic disease]] include: <ref name="pmid9490607">{{cite journal |vauthors=Galvañ VG |title=Sister Mary Joseph's nodule |journal=Ann. Intern. Med. |volume=128 |issue=5 |pages=410 |year=1998 |pmid=9490607 |doi= |url=}}</ref>
**Left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]])
**Palpable periumbilical mass (''Sister Mary Joseph's node'')  
**[[Metastasis|Metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'')
**Involvement of other [[Lymph node|nodes]] in the [[cervical]] area


:#a more early but likely expensive genetic and biochemical molecular [[Screening (medicine)|screening]] test profile, which would be an innovation in this cancer;
===Abdomen===
:#also possible new, creative and more effective therapies based on the various microRNA levels. This opens an exciting new front in confronting a very deadly disease.
Abdominal examination is as follows: <ref name="pmid8780535">{{cite journal |vauthors=Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T |title=Clinicopathologic features of small pancreatic adenocarcinoma. A collective study |journal=Cancer |volume=78 |issue=5 |pages=986–90 |year=1996 |pmid=8780535 |doi=10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A |url=}}</ref><ref name="pmid3942423">{{cite journal |vauthors=Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R |title=Collective review of small carcinomas of the pancreas |journal=Ann. Surg. |volume=203 |issue=1 |pages=77–81 |year=1986 |pmid=3942423 |pmc=1251042 |doi= |url=}}</ref><ref name="pmid11075985">{{cite journal |vauthors=Mujica VR, Barkin JS, Go VL |title=Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants |journal=Pancreas |volume=21 |issue=4 |pages=329–32 |year=2000 |pmid=11075985 |doi= |url=}}</ref>
*[[Abdominal distention]]
*[[Abdominal tenderness]]:
**Site: [[tenderness]] in [[Epigastric|mid epigastric]] region 
**Onset: insidious 
**Character: gnawing, visceral quality 
**Radiation- mid/lower back due to [[tumor]] invasion of the [[Retroperitoneum|retroperitoneal]] [[Splanchnic nerve|splanchnic nerve plexus]] 
**Relieving factors: relieved on lying down in a curled or [[Fetus|fetal]] position may improve the pain 
**Aggravating factors: worse on lying supine or eating 
**Timing: intermittent 
**Severity- mild-moderate, worse at night
*An [[abdominal mass]] may be palpable in the epigastrium.
*[[Hepatomegaly]] may arise from liver [[metastasis]]
*[[splenomegaly]] may arise from portal vein obstruction
*[[hepatosplenomegaly]]
*Fluid thrill and dullness to [[percussion]] may be present due to [[ascites]]


As a summary; tests that examine the pancreas are used to detect (find), diagnose, and stage pancreatic cancer as follow:
===Genitourinary===
* Physical exam and history
*In advanced stages of [[pancreatic cancer]], [[Metastasis|metastatic]] palpable mass may be present in the [[rectal]] pouch.(''Blumer's shelf'')
* Tumor markers
* Chest x-ray
* CT scan (CAT scan)
* MRI (magnetic resonance imaging)
* PET scan (positron emission tomography scan)
* Endoscopic ultrasound (EUS): This procedure is also called endosonography.
* Laparoscopy
* Endoscopic retrograde cholangiopancreatography (ERCP)
* Percutaneous transhepatic cholangiography (PTC): This test is done only if ERCP cannot be done.
* Biopsy


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatospleenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.

Physical Examination

Appearance of the Patient

Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatosplenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.

Vital Signs

Skin

Skin findings are as follows: [1][2][3][4][5]

The following picture depicts bullous pemphigoid lesions in a patient:

CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781

{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}

Neck

Abdomen

Abdominal examination is as follows: [8][9][10]

Genitourinary

References

  1. ↑ Kalser MH, Barkin J, MacIntyre JM (1985). "Pancreatic cancer. Assessment of prognosis by clinical presentation". Cancer. 56 (2): 397–402. PMID 4005804.
  2. ↑ Khorana AA, Fine RL (2004). "Pancreatic cancer and thromboembolic disease". Lancet Oncol. 5 (11): 655–63. doi:10.1016/S1470-2045(04)01606-7. PMID 15522652.
  3. ↑ Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G (1986). "Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center". J. Clin. Oncol. 4 (4): 509–14. doi:10.1200/JCO.1986.4.4.509. PMID 3958764.
  4. ↑ Ostlere LS, Branfoot AC, Staughton RC (1992). "Cicatricial pemphigoid and carcinoma of the pancreas". Clin. Exp. Dermatol. 17 (1): 67–8. PMID 1330387.
  5. ↑ Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T (1988). "Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients". Cancer. 62 (1): 135–41. PMID 3164230.
  6. ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
  7. ↑ Galvañ VG (1998). "Sister Mary Joseph's nodule". Ann. Intern. Med. 128 (5): 410. PMID 9490607.
  8. ↑ Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T (1996). "Clinicopathologic features of small pancreatic adenocarcinoma. A collective study". Cancer. 78 (5): 986–90. doi:10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A. PMID 8780535.
  9. ↑ Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R (1986). "Collective review of small carcinomas of the pancreas". Ann. Surg. 203 (1): 77–81. PMC 1251042. PMID 3942423.
  10. ↑ Mujica VR, Barkin JS, Go VL (2000). "Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants". Pancreas. 21 (4): 329–32. PMID 11075985.

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