Pancreatic cancer differential diagnosis: Difference between revisions

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==Differentiating Pancreatic Cancer from other Diseases==
==Differentiating Pancreatic Cancer from other Diseases==


The differentials for [[pancreatic cancer]] mainly involve pathologies of the [[pancreas]], [[bile duct]], [[duodenum]], lymphovascular tissue or [[metastasis]] from other sites. It is difficult to differentiate pancreatic cancer from other neoplasms as they all present with non specific constitutional symptoms. Hence, differentiation is primarily based on investigations:<ref name="pmid29029521">{{cite journal |vauthors=He XK, Ding Y, Sun LM |title=Contrast-enhanced endoscopic ultrasound for differential diagnosis of pancreatic cancer: an updated meta-analysis |journal=Oncotarget |volume=8 |issue=39 |pages=66392–66401 |year=2017 |pmid=29029521 |pmc=5630421 |doi=10.18632/oncotarget.18915 |url=}}</ref><ref name="pmid29022085">{{cite journal |vauthors=Steinman J, Zaheer A, Kluger MD, Remotti H, Hecht EM |title=Rare pancreatic tumors |journal=Abdom Radiol (NY) |volume= |issue= |pages= |year=2017 |pmid=29022085 |doi=10.1007/s00261-017-1342-x |url=}}</ref><ref name="pmid28700485">{{cite journal |vauthors=Ran L, Zhao W, Zhao Y, Bu H |title=Value of contrast-enhanced ultrasound in differential diagnosis of solid lesions of pancreas (SLP): A systematic review and a meta-analysis |journal=Medicine (Baltimore) |volume=96 |issue=28 |pages=e7463 |year=2017 |pmid=28700485 |pmc=5515757 |doi=10.1097/MD.0000000000007463 |url=}}</ref><ref name="pmid28216481">{{cite journal |vauthors=Kołodziejczyk E, Wejnarska K, Oracz G |title=Autoimmune pancreatitis in the paediatric population - review of the literature and own experience |journal=Dev Period Med |volume=20 |issue=4 |pages=279–286 |year=2016 |pmid=28216481 |doi= |url=}}</ref><ref name="pmid28197876">{{cite journal |vauthors=Zhu L, Xue HD, Liu W, Wang X, Sui X, Wang Q, Zhang D, Li P, Jin ZY |title=Enhancing pancreatic mass with normal serum CA19-9: key MDCT features to characterize pancreatic neuroendocrine tumours from its mimics |journal=Radiol Med |volume=122 |issue=5 |pages=337–344 |year=2017 |pmid=28197876 |doi=10.1007/s11547-017-0734-x |url=}}</ref><ref name="pmid28154274">{{cite journal |vauthors=Sano I, Katanuma A, Yane K, Kin T, Nagai K, Yamazaki H, Koga H, Kitagawa K, Yokoyama K, Ikarashi S, Takahashi K, Maguchi H, Omori Y, Shinohara T |title=Pancreatic Metastasis from Rectal Cancer that was Diagnosed by Endoscopic Ultrasonography-guided Fine Needle Aspiration (EUS-FNA) |journal=Intern. Med. |volume=56 |issue=3 |pages=301–305 |year=2017 |pmid=28154274 |pmc=5348454 |doi=10.2169/internalmedicine.56.7213 |url=}}</ref><ref name="pmid27926362">{{cite journal |vauthors=Salaria SN, Shi C |title=Pancreatic Neuroendocrine Tumors |journal=Surg Pathol Clin |volume=9 |issue=4 |pages=595–617 |year=2016 |pmid=27926362 |doi=10.1016/j.path.2016.05.006 |url=}}</ref><ref name="pmid27803081">{{cite journal |vauthors=Kawasaki K, Kawaguchi Y, Suzuki Y, Tanaka N |title=Renal neuroendocrine tumour and synchronous pancreas metastasis: histopathological diagnosis using prostatic acid phosphatase |journal=BMJ Case Rep |volume=2016 |issue= |pages= |year=2016 |pmid=27803081 |doi=10.1136/bcr-2016-214759 |url=}}</ref><ref name="pmid27673319">{{cite journal |vauthors=Nassour I, Choti MA |title=Diagnosis and Treatment of Pancreatic Cystic Neoplasms |journal=JAMA |volume=316 |issue=12 |pages=1326 |year=2016 |pmid=27673319 |doi=10.1001/jama.2016.9130 |url=}}</ref><ref name="pmid28418702">{{cite journal |vauthors=Javadi S, Menias CO, Korivi BR, Shaaban AM, Patnana M, Alhalabi K, Elsayes KM |title=Pancreatic Calcifications and Calcified Pancreatic Masses: Pattern Recognition Approach on CT |journal=AJR Am J Roentgenol |volume=209 |issue=1 |pages=77–87 |year=2017 |pmid=28418702 |doi=10.2214/AJR.17.17862 |url=}}</ref><ref name="pmid27807633">{{cite journal |vauthors=Bergmann F |title=[Pancreatic acinar neoplasms : Comparative molecular characterization] |language=German |journal=Pathologe |volume=37 |issue=Suppl 2 |pages=191–195 |year=2016 |pmid=27807633 |doi=10.1007/s00292-016-0235-z |url=}}</ref><ref name="pmid27232353">{{cite journal |vauthors=Cheng SK, Chuah KL |title=Metastatic Renal Cell Carcinoma to the Pancreas: A Review |journal=Arch. Pathol. Lab. Med. |volume=140 |issue=6 |pages=598–602 |year=2016 |pmid=27232353 |doi=10.5858/arpa.2015-0135-RS |url=}}</ref><ref name="pmid27000276">{{cite journal |vauthors=Haage P, Schwartz CA, Scharwächter C |title=[Ductal adenocarcinoma and unusual differential diagnosis] |language=German |journal=Radiologe |volume=56 |issue=4 |pages=325–37 |year=2016 |pmid=27000276 |doi=10.1007/s00117-016-0090-1 |url=}}</ref><ref name="pmid26777740">{{cite journal |vauthors=Scialpi M, Reginelli A, D'Andrea A, Gravante S, Falcone G, Baccari P, Manganaro L, Palumbo B, Cappabianca S |title=Pancreatic tumors imaging: An update |journal=Int J Surg |volume=28 Suppl 1 |issue= |pages=S142–55 |year=2016 |pmid=26777740 |doi=10.1016/j.ijsu.2015.12.053 |url=}}</ref><ref name="pmid25799073">{{cite journal |vauthors=Senosiain Lalastra C, Foruny Olcina JR |title=[Autoimmune pancreatitis] |language=Spanish; Castilian |journal=Gastroenterol Hepatol |volume=38 |issue=9 |pages=549–55 |year=2015 |pmid=25799073 |doi=10.1016/j.gastrohep.2015.01.006 |url=}}</ref><ref name="pmid25638877">{{cite journal |vauthors=Barbier L, Delpero JR |title=[Pancreatic tumours] |language=French |journal=Rev Prat |volume=64 |issue=9 |pages=1307–12 |year=2014 |pmid=25638877 |doi= |url=}}</ref><ref name="pmid25288201">{{cite journal |vauthors=Díte P, Uvírová M, Bojková M, Novotný I, Dvorácková J, Kianicka B, Nechutová H, Dovrtelová L, Floreánová K, Martínek A |title=Differentiating autoimmune pancreatitis from pancreatic cancer |journal=Minerva Gastroenterol Dietol |volume=60 |issue=4 |pages=247–53 |year=2014 |pmid=25288201 |doi= |url=}}</ref><ref name="pmid25063236">{{cite journal |vauthors=Lalwani N, Mannelli L, Ganeshan DM, Shanbhogue AK, Dighe MK, Tiwari HA, Maximin S, Monti S, Ragucci M, Prasad SR |title=Uncommon pancreatic tumors and pseudotumors |journal=Abdom Imaging |volume=40 |issue=1 |pages=167–80 |year=2015 |pmid=25063236 |doi=10.1007/s00261-014-0189-7 |url=}}</ref><ref name="pmid24572485">{{cite journal |vauthors=Dite P, Nechutova H, Uvirova M, Dvorackova J, Kianicka B, Martinek A |title=Autoimmune pancreatitis |journal=Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub |volume=158 |issue=1 |pages=17–22 |year=2014 |pmid=24572485 |doi=10.5507/bp.2013.094 |url=}}</ref><ref name="pmid24242859">{{cite journal |vauthors=Mastoraki A, Tzortzopoulou A, Tsela S, Danias N, Sakorafas G, Smyrniotis V, Arkadopoulos N |title=Hereditary pancreatitis: dilemmas in differential diagnosis and therapeutic approach |journal=J Gastrointest Cancer |volume=45 |issue=1 |pages=22–6 |year=2014 |pmid=24242859 |doi=10.1007/s12029-013-9559-6 |url=}}</ref><ref name="pmid24193862">{{cite journal |vauthors=Beyer G, Menzel J, Krüger PC, Ribback S, Lerch MM, Mayerle J |title=[Autoimmune pancreatitis] |language=German |journal=Dtsch. Med. Wochenschr. |volume=138 |issue=46 |pages=2359–70; quiz 2371–4 |year=2013 |pmid=24193862 |doi=10.1055/s-0033-1349475 |url=}}</ref><ref name="pmid24060833">{{cite journal |vauthors=Al-Hawary MM, Kaza RK, Azar SF, Ruma JA, Francis IR |title=Mimics of pancreatic ductal adenocarcinoma |journal=Cancer Imaging |volume=13 |issue=3 |pages=342–9 |year=2013 |pmid=24060833 |pmc=3800430 |doi=10.1102/1470-7330.2013.9012 |url=}}</ref><ref name="pmid23918083">{{cite journal |vauthors=Bednar F, Scheiman JM, McKenna BJ, Simeone DM |title=Breast cancer metastases to the pancreas |journal=J. Gastrointest. Surg. |volume=17 |issue=10 |pages=1826–31 |year=2013 |pmid=23918083 |doi=10.1007/s11605-013-2291-5 |url=}}</ref><ref name="pmid23852141">{{cite journal |vauthors=DiMagno MJ, DiMagno EP |title=Chronic pancreatitis |journal=Curr. Opin. Gastroenterol. |volume=29 |issue=5 |pages=531–6 |year=2013 |pmid=23852141 |pmc=4387887 |doi=10.1097/MOG.0b013e3283639370 |url=}}</ref><ref name="pmid28831506">{{cite journal |vauthors=Berger AW, Seufferlein T, Kleger A |title=[Cystic pancreatic tumors: diagnostics and new biomarkers] |language=German |journal=Chirurg |volume=88 |issue=11 |pages=905–912 |year=2017 |pmid=28831506 |doi=10.1007/s00104-017-0493-1 |url=}}</ref><ref name="pmid27840080">{{cite journal |vauthors=Nougaret S, Mannelli L, Pierredon MA, Schembri V, Guiu B |title=Cystic pancreatic lesions: From increased diagnosis rate to new dilemmas |journal=Diagn Interv Imaging |volume=97 |issue=12 |pages=1275–1285 |year=2016 |pmid=27840080 |doi=10.1016/j.diii.2016.08.017 |url=}}</ref><ref name="pmid28858107">{{cite journal |vauthors=Xu MM, Yin S, Siddiqui AA, Salem RR, Schrope B, Sethi A, Poneros JM, Gress FG, Genkinger JM, Do C, Brooks CA, Chabot JA, Kluger MD, Kowalski T, Loren DE, Aslanian H, Farrell JJ, Gonda TA |title=Comparison of the diagnostic accuracy of three current guidelines for the evaluation of asymptomatic pancreatic cystic neoplasms |journal=Medicine (Baltimore) |volume=96 |issue=35 |pages=e7900 |year=2017 |pmid=28858107 |pmc=5585501 |doi=10.1097/MD.0000000000007900 |url=}}</ref><ref name="pmid26818541">{{cite journal |vauthors=Dong J, Cong L, Zhang TP, Zhao YP |title=Pancreatic metastasis of renal cell carcinoma |journal=HBPD INT |volume=15 |issue=1 |pages=30–8 |year=2016 |pmid=26818541 |doi= |url=}}</ref>
{| class="wikitable"
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Origin
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Disease
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Differentiation based on Investigations
|-
| style="background:#DCDCDC; + " | '''Pancreas'''
|
* [[Chronic pancreatitis]]
* [[Autoimmune pancreatitis]]
* [[Pancreatic pseudocyst|Pseudocyst]] of [[pancreas]]
* [[Pancreatic cyst]]
* [[Neuroendocrine tumors|Neuroendocrine tumors of pancreas]]
** [[Gastrinoma (patient information)|Gastrinoma]]
** [[VIPoma]]
** [[Neuroendocrine tumors|Somatostatinoma]]
** [[Insulinoma]]
|
* [[Imaging]]: Non-contrast helical [[Computed tomography|CT]]
* [[Biopsy]] findings
* Serum [[IgG4-related systemic disease|IgG4]] levels for autoimmune pancreatitis
* For pancreatic [[Neuroendocrine tumors|NETs]]:
** [[Gastrin]] levels
** [[Somatostatin]] levels
** [[Insulin]] levels
** Serum electrolytes
|-
| style="background:#DCDCDC; + " | '''Bile duct'''
|
* [[Choledocholithiasis]]
* [[Gallstone disease|Gallstones]] ([[Gallstone disease|Cholelithiasis]])
* [[Bile duct cyst|Choledochal Cysts]]
* [[Cholangiocarcinoma]]
* [[Bile duct]] [[Stenosis|strictures]]
* [[Cholangitis]]
* [[Cholecystitis]]
|
* [[Imaging]]:
** [[Magnetic resonance imaging|MRI]]
** [[Magnetic resonance cholangiopancreatography|MRCP]]
** [[Ultrasound|USG bile duct]]
** [[Endoscopic retrograde cholangiopancreatography|ERCP]]
* [[Biopsy]] findings
|-
| style="background:#DCDCDC; + " | '''Duodenum'''
|
* Ampullary cancer
* [[Duodenum|Duodenal]] cancer
|
* [[Imaging]]:
** [[Magnetic resonance imaging|MRI]]
** [[Endoscopic retrograde cholangiopancreatography|ERCP]]
** Upper [[Gastrointestinal tract|GI]] [[Endoscopy]]
* [[Biopsy]] findings
|-
| style="background:#DCDCDC; + " | '''Lymphovascular'''
'''tissue'''
|
* [[Abdominal aortic aneurysm]]
* [[Mesenteric ischemia|Intestinal ischemia]]
* [[Lymphoma|Lymphomas]]
** [[Stomach|Gastric]]
** [[Pancreas|Pancreatic]]
|
* Imaging:
** [[Magnetic resonance imaging|MRI]]
** MR [[Angiogram|Angiography]]
** CT [[Angiogram|Angiography]]
* [[Biopsy]] for [[lymphoma]]
|-
| style="background:#DCDCDC; + " | '''Metastasis'''
|
* [[Skin]]([[Melanoma]])
* [[Kidney]]
* [[Breast]]
* [[Colon (anatomy)|Colon]]
* [[Liver]]([[Hepatocellular carcinoma]])
* [[Stomach]]
|
* [[Imaging]]:
** [[Magnetic resonance imaging|MRI]]
** [[Positron emission tomography|PET scan]]
** [[Computed tomography|CT]]
* [[Biopsy]]
* Specific markers for different [[Cancer|cancers]]:
** [[Hepatocellular carcinoma|HCC]]: [[Alpha-fetoprotein|AFP]]
** [[Breast]]: ''BRCA 1 and 2''
** [[Colorectal cancer|Colon cancer]]: [[CEA]]
** [[Melanoma]]: [[S100B|S100]]
|}


[[Pancreatic cancer]] may also be distinguished from other causes of [[abdominal pain]] and [[jaundice]] as depicted in the table below:
[[Pancreatic cancer]] may also be distinguished from other causes of [[abdominal pain]] and [[jaundice]] as depicted in the table below:
Line 756: Line 666:
| <figure-inline class="mw-default-size"><figure-inline><figure-inline>[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]</figure-inline></figure-inline></figure-inline>||<figure-inline class="mw-default-size"><figure-inline><figure-inline>[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]</figure-inline></figure-inline></figure-inline>||<figure-inline class="mw-default-size"><figure-inline><figure-inline>[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]</figure-inline></figure-inline></figure-inline>
| <figure-inline class="mw-default-size"><figure-inline><figure-inline>[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]</figure-inline></figure-inline></figure-inline>||<figure-inline class="mw-default-size"><figure-inline><figure-inline>[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]</figure-inline></figure-inline></figure-inline>||<figure-inline class="mw-default-size"><figure-inline><figure-inline>[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]</figure-inline></figure-inline></figure-inline>
|}
|}
The differentials for [[pancreatic cancer]] mainly involve pathologies of the [[pancreas]], [[bile duct]], [[duodenum]], lymphovascular tissue or [[metastasis]] from other sites. It is difficult to differentiate pancreatic cancer from other neoplasms as they all present with non specific constitutional symptoms. Hence, differentiation is primarily based on investigations:<ref name="pmid29029521">{{cite journal |vauthors=He XK, Ding Y, Sun LM |title=Contrast-enhanced endoscopic ultrasound for differential diagnosis of pancreatic cancer: an updated meta-analysis |journal=Oncotarget |volume=8 |issue=39 |pages=66392–66401 |year=2017 |pmid=29029521 |pmc=5630421 |doi=10.18632/oncotarget.18915 |url=}}</ref><ref name="pmid29022085">{{cite journal |vauthors=Steinman J, Zaheer A, Kluger MD, Remotti H, Hecht EM |title=Rare pancreatic tumors |journal=Abdom Radiol (NY) |volume= |issue= |pages= |year=2017 |pmid=29022085 |doi=10.1007/s00261-017-1342-x |url=}}</ref><ref name="pmid28700485">{{cite journal |vauthors=Ran L, Zhao W, Zhao Y, Bu H |title=Value of contrast-enhanced ultrasound in differential diagnosis of solid lesions of pancreas (SLP): A systematic review and a meta-analysis |journal=Medicine (Baltimore) |volume=96 |issue=28 |pages=e7463 |year=2017 |pmid=28700485 |pmc=5515757 |doi=10.1097/MD.0000000000007463 |url=}}</ref><ref name="pmid28216481">{{cite journal |vauthors=Kołodziejczyk E, Wejnarska K, Oracz G |title=Autoimmune pancreatitis in the paediatric population - review of the literature and own experience |journal=Dev Period Med |volume=20 |issue=4 |pages=279–286 |year=2016 |pmid=28216481 |doi= |url=}}</ref><ref name="pmid28197876">{{cite journal |vauthors=Zhu L, Xue HD, Liu W, Wang X, Sui X, Wang Q, Zhang D, Li P, Jin ZY |title=Enhancing pancreatic mass with normal serum CA19-9: key MDCT features to characterize pancreatic neuroendocrine tumours from its mimics |journal=Radiol Med |volume=122 |issue=5 |pages=337–344 |year=2017 |pmid=28197876 |doi=10.1007/s11547-017-0734-x |url=}}</ref><ref name="pmid28154274">{{cite journal |vauthors=Sano I, Katanuma A, Yane K, Kin T, Nagai K, Yamazaki H, Koga H, Kitagawa K, Yokoyama K, Ikarashi S, Takahashi K, Maguchi H, Omori Y, Shinohara T |title=Pancreatic Metastasis from Rectal Cancer that was Diagnosed by Endoscopic Ultrasonography-guided Fine Needle Aspiration (EUS-FNA) |journal=Intern. Med. |volume=56 |issue=3 |pages=301–305 |year=2017 |pmid=28154274 |pmc=5348454 |doi=10.2169/internalmedicine.56.7213 |url=}}</ref><ref name="pmid27926362">{{cite journal |vauthors=Salaria SN, Shi C |title=Pancreatic Neuroendocrine Tumors |journal=Surg Pathol Clin |volume=9 |issue=4 |pages=595–617 |year=2016 |pmid=27926362 |doi=10.1016/j.path.2016.05.006 |url=}}</ref><ref name="pmid27803081">{{cite journal |vauthors=Kawasaki K, Kawaguchi Y, Suzuki Y, Tanaka N |title=Renal neuroendocrine tumour and synchronous pancreas metastasis: histopathological diagnosis using prostatic acid phosphatase |journal=BMJ Case Rep |volume=2016 |issue= |pages= |year=2016 |pmid=27803081 |doi=10.1136/bcr-2016-214759 |url=}}</ref><ref name="pmid27673319">{{cite journal |vauthors=Nassour I, Choti MA |title=Diagnosis and Treatment of Pancreatic Cystic Neoplasms |journal=JAMA |volume=316 |issue=12 |pages=1326 |year=2016 |pmid=27673319 |doi=10.1001/jama.2016.9130 |url=}}</ref><ref name="pmid28418702">{{cite journal |vauthors=Javadi S, Menias CO, Korivi BR, Shaaban AM, Patnana M, Alhalabi K, Elsayes KM |title=Pancreatic Calcifications and Calcified Pancreatic Masses: Pattern Recognition Approach on CT |journal=AJR Am J Roentgenol |volume=209 |issue=1 |pages=77–87 |year=2017 |pmid=28418702 |doi=10.2214/AJR.17.17862 |url=}}</ref><ref name="pmid27807633">{{cite journal |vauthors=Bergmann F |title=[Pancreatic acinar neoplasms : Comparative molecular characterization] |language=German |journal=Pathologe |volume=37 |issue=Suppl 2 |pages=191–195 |year=2016 |pmid=27807633 |doi=10.1007/s00292-016-0235-z |url=}}</ref><ref name="pmid27232353">{{cite journal |vauthors=Cheng SK, Chuah KL |title=Metastatic Renal Cell Carcinoma to the Pancreas: A Review |journal=Arch. Pathol. Lab. Med. |volume=140 |issue=6 |pages=598–602 |year=2016 |pmid=27232353 |doi=10.5858/arpa.2015-0135-RS |url=}}</ref><ref name="pmid27000276">{{cite journal |vauthors=Haage P, Schwartz CA, Scharwächter C |title=[Ductal adenocarcinoma and unusual differential diagnosis] |language=German |journal=Radiologe |volume=56 |issue=4 |pages=325–37 |year=2016 |pmid=27000276 |doi=10.1007/s00117-016-0090-1 |url=}}</ref><ref name="pmid26777740">{{cite journal |vauthors=Scialpi M, Reginelli A, D'Andrea A, Gravante S, Falcone G, Baccari P, Manganaro L, Palumbo B, Cappabianca S |title=Pancreatic tumors imaging: An update |journal=Int J Surg |volume=28 Suppl 1 |issue= |pages=S142–55 |year=2016 |pmid=26777740 |doi=10.1016/j.ijsu.2015.12.053 |url=}}</ref><ref name="pmid25799073">{{cite journal |vauthors=Senosiain Lalastra C, Foruny Olcina JR |title=[Autoimmune pancreatitis] |language=Spanish; Castilian |journal=Gastroenterol Hepatol |volume=38 |issue=9 |pages=549–55 |year=2015 |pmid=25799073 |doi=10.1016/j.gastrohep.2015.01.006 |url=}}</ref><ref name="pmid25638877">{{cite journal |vauthors=Barbier L, Delpero JR |title=[Pancreatic tumours] |language=French |journal=Rev Prat |volume=64 |issue=9 |pages=1307–12 |year=2014 |pmid=25638877 |doi= |url=}}</ref><ref name="pmid25288201">{{cite journal |vauthors=Díte P, Uvírová M, Bojková M, Novotný I, Dvorácková J, Kianicka B, Nechutová H, Dovrtelová L, Floreánová K, Martínek A |title=Differentiating autoimmune pancreatitis from pancreatic cancer |journal=Minerva Gastroenterol Dietol |volume=60 |issue=4 |pages=247–53 |year=2014 |pmid=25288201 |doi= |url=}}</ref><ref name="pmid25063236">{{cite journal |vauthors=Lalwani N, Mannelli L, Ganeshan DM, Shanbhogue AK, Dighe MK, Tiwari HA, Maximin S, Monti S, Ragucci M, Prasad SR |title=Uncommon pancreatic tumors and pseudotumors |journal=Abdom Imaging |volume=40 |issue=1 |pages=167–80 |year=2015 |pmid=25063236 |doi=10.1007/s00261-014-0189-7 |url=}}</ref><ref name="pmid24572485">{{cite journal |vauthors=Dite P, Nechutova H, Uvirova M, Dvorackova J, Kianicka B, Martinek A |title=Autoimmune pancreatitis |journal=Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub |volume=158 |issue=1 |pages=17–22 |year=2014 |pmid=24572485 |doi=10.5507/bp.2013.094 |url=}}</ref><ref name="pmid24242859">{{cite journal |vauthors=Mastoraki A, Tzortzopoulou A, Tsela S, Danias N, Sakorafas G, Smyrniotis V, Arkadopoulos N |title=Hereditary pancreatitis: dilemmas in differential diagnosis and therapeutic approach |journal=J Gastrointest Cancer |volume=45 |issue=1 |pages=22–6 |year=2014 |pmid=24242859 |doi=10.1007/s12029-013-9559-6 |url=}}</ref><ref name="pmid24193862">{{cite journal |vauthors=Beyer G, Menzel J, Krüger PC, Ribback S, Lerch MM, Mayerle J |title=[Autoimmune pancreatitis] |language=German |journal=Dtsch. Med. Wochenschr. |volume=138 |issue=46 |pages=2359–70; quiz 2371–4 |year=2013 |pmid=24193862 |doi=10.1055/s-0033-1349475 |url=}}</ref><ref name="pmid24060833">{{cite journal |vauthors=Al-Hawary MM, Kaza RK, Azar SF, Ruma JA, Francis IR |title=Mimics of pancreatic ductal adenocarcinoma |journal=Cancer Imaging |volume=13 |issue=3 |pages=342–9 |year=2013 |pmid=24060833 |pmc=3800430 |doi=10.1102/1470-7330.2013.9012 |url=}}</ref><ref name="pmid23918083">{{cite journal |vauthors=Bednar F, Scheiman JM, McKenna BJ, Simeone DM |title=Breast cancer metastases to the pancreas |journal=J. Gastrointest. Surg. |volume=17 |issue=10 |pages=1826–31 |year=2013 |pmid=23918083 |doi=10.1007/s11605-013-2291-5 |url=}}</ref><ref name="pmid23852141">{{cite journal |vauthors=DiMagno MJ, DiMagno EP |title=Chronic pancreatitis |journal=Curr. Opin. Gastroenterol. |volume=29 |issue=5 |pages=531–6 |year=2013 |pmid=23852141 |pmc=4387887 |doi=10.1097/MOG.0b013e3283639370 |url=}}</ref><ref name="pmid28831506">{{cite journal |vauthors=Berger AW, Seufferlein T, Kleger A |title=[Cystic pancreatic tumors: diagnostics and new biomarkers] |language=German |journal=Chirurg |volume=88 |issue=11 |pages=905–912 |year=2017 |pmid=28831506 |doi=10.1007/s00104-017-0493-1 |url=}}</ref><ref name="pmid27840080">{{cite journal |vauthors=Nougaret S, Mannelli L, Pierredon MA, Schembri V, Guiu B |title=Cystic pancreatic lesions: From increased diagnosis rate to new dilemmas |journal=Diagn Interv Imaging |volume=97 |issue=12 |pages=1275–1285 |year=2016 |pmid=27840080 |doi=10.1016/j.diii.2016.08.017 |url=}}</ref><ref name="pmid28858107">{{cite journal |vauthors=Xu MM, Yin S, Siddiqui AA, Salem RR, Schrope B, Sethi A, Poneros JM, Gress FG, Genkinger JM, Do C, Brooks CA, Chabot JA, Kluger MD, Kowalski T, Loren DE, Aslanian H, Farrell JJ, Gonda TA |title=Comparison of the diagnostic accuracy of three current guidelines for the evaluation of asymptomatic pancreatic cystic neoplasms |journal=Medicine (Baltimore) |volume=96 |issue=35 |pages=e7900 |year=2017 |pmid=28858107 |pmc=5585501 |doi=10.1097/MD.0000000000007900 |url=}}</ref><ref name="pmid26818541">{{cite journal |vauthors=Dong J, Cong L, Zhang TP, Zhao YP |title=Pancreatic metastasis of renal cell carcinoma |journal=HBPD INT |volume=15 |issue=1 |pages=30–8 |year=2016 |pmid=26818541 |doi= |url=}}</ref>
{| class="wikitable"
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Origin
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Disease
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Differentiation based on Investigations
|-
| style="background:#DCDCDC; + " | '''Pancreas'''
|
* [[Chronic pancreatitis]]
* [[Autoimmune pancreatitis]]
* [[Pancreatic pseudocyst|Pseudocyst]] of [[pancreas]]
* [[Pancreatic cyst]]
* [[Neuroendocrine tumors|Neuroendocrine tumors of pancreas]]
** [[Gastrinoma (patient information)|Gastrinoma]]
** [[VIPoma]]
** [[Neuroendocrine tumors|Somatostatinoma]]
** [[Insulinoma]]
|
* [[Imaging]]: Non-contrast helical [[Computed tomography|CT]]
* [[Biopsy]] findings
* Serum [[IgG4-related systemic disease|IgG4]] levels for autoimmune pancreatitis
* For pancreatic [[Neuroendocrine tumors|NETs]]:
** [[Gastrin]] levels
** [[Somatostatin]] levels
** [[Insulin]] levels
** Serum electrolytes
|-
| style="background:#DCDCDC; + " | '''Bile duct'''
|
* [[Choledocholithiasis]]
* [[Gallstone disease|Gallstones]] ([[Gallstone disease|Cholelithiasis]])
* [[Bile duct cyst|Choledochal Cysts]]
* [[Cholangiocarcinoma]]
* [[Bile duct]] [[Stenosis|strictures]]
* [[Cholangitis]]
* [[Cholecystitis]]
|
* [[Imaging]]:
** [[Magnetic resonance imaging|MRI]]
** [[Magnetic resonance cholangiopancreatography|MRCP]]
** [[Ultrasound|USG bile duct]]
** [[Endoscopic retrograde cholangiopancreatography|ERCP]]
* [[Biopsy]] findings
|-
| style="background:#DCDCDC; + " | '''Duodenum'''
|
* Ampullary cancer
* [[Duodenum|Duodenal]] cancer
|
* [[Imaging]]:
** [[Magnetic resonance imaging|MRI]]
** [[Endoscopic retrograde cholangiopancreatography|ERCP]]
** Upper [[Gastrointestinal tract|GI]] [[Endoscopy]]
* [[Biopsy]] findings
|-
| style="background:#DCDCDC; + " | '''Lymphovascular'''
'''tissue'''
|
* [[Abdominal aortic aneurysm]]
* [[Mesenteric ischemia|Intestinal ischemia]]
* [[Lymphoma|Lymphomas]]
** [[Stomach|Gastric]]
** [[Pancreas|Pancreatic]]
|
* Imaging:
** [[Magnetic resonance imaging|MRI]]
** MR [[Angiogram|Angiography]]
** CT [[Angiogram|Angiography]]
* [[Biopsy]] for [[lymphoma]]
|-
| style="background:#DCDCDC; + " | '''Metastasis'''
|
* [[Skin]]([[Melanoma]])
* [[Kidney]]
* [[Breast]]
* [[Colon (anatomy)|Colon]]
* [[Liver]]([[Hepatocellular carcinoma]])
* [[Stomach]]
|
* [[Imaging]]:
** [[Magnetic resonance imaging|MRI]]
** [[Positron emission tomography|PET scan]]
** [[Computed tomography|CT]]
* [[Biopsy]]
* Specific markers for different [[Cancer|cancers]]:
** [[Hepatocellular carcinoma|HCC]]: [[Alpha-fetoprotein|AFP]]
** [[Breast]]: ''BRCA 1 and 2''
** [[Colorectal cancer|Colon cancer]]: [[CEA]]
** [[Melanoma]]: [[S100B|S100]]
|}


==References==
==References==

Revision as of 02:08, 16 November 2017

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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

Pancreatic cancer must be differentiated from other pancreatic pathologies such as chronic pancreatitis, autoimmune pancreatitis, pancreatic pseudocyst, and neuroendocrine tumors of the pancreas. Pathologies of the bile duct and duodenum such as Choledocholithiasis, gallstones (Cholelithiasis), Choledochal Cysts, Cholangiocarcinoma, Bile duct strictures and ampullary cancer should be differentiated from pancreatic cancer based on imaging and biopsy findings. Metastasis from different sites and vascular causes such as abdominal aortic aneurysms may also mimic pancreatic cancer.

Differentiating Pancreatic Cancer from other Diseases

Pancreatic cancer may also be distinguished from other causes of abdominal pain and jaundice as depicted in the table below:

Classification of acute abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis + + RUQ + + + + N
  • Abnormal LFT
  • WBC >10,000
 Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS
Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + − RUQ + − − − Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + − Epigastric ± ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Primary biliary cirrhosis − − RUQ/Epigastric + − − − N Increased AMA level, abnormal LFTs
Primary sclerosing cholangitis + − RUQ + − − − N
Cholelithiasis ± − RUQ/Epigastric ± − + + N to hyperactive for dislodged stone Leukocytosis Ultrasound shows gallstone Murphy’s sign
Pancreatic cancer − − Epigastric ± − − − N

 ill defined hypoechoic mass is seen infiltrating into a bright pancreatic parenchyma

Signs of metastatic disease include: 
Gastric causes Peptic ulcer disease ± − Diffuse − + in perforated + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
 Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Gastritis ± − Epigastric
Gastroesophageal reflux disease − − Epigastric − − − −
Gastric outlet obstruction − − Epigastric − ± Hyperactive
Gastrointestinal perforation + ± Diffuse ± + + ± WBC> 10,000 Air under diaphragm in upright CXR
Intestinal causes Acute appendicitis + +in pyogenic appendicitis Starts in epigastrium, migrates to RLQ − + in perforated appendicitis + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + ± LLQ − − + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Inflammatory bowel disease ± − Diffuse
Irritable bowel syndrome ± − Diffuse − − − − N Tests done to exclude other diseases as it diagnosis of exclusion Tests done to exclude other diseases as it diagnosis of exclusion Symptomatic treatment
Whipple's disease ± − Diffuse ± ± − − N *Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Toxic megacolon + − Diffuse − + ± − Hypoactive
Tropical sprue + − Diffuse
Celiac disease − − Diffuse ±, also dermatitis herpetiformis − − − Hyperactive (increased sounds)
Hepatic causes Viral hepatitis + − RUQ + − +
Liver masses + + in Liver abscess RUQ ± + in sepsis
Budd-Chiari syndrome ± − RUQ −
Hemochromatosis − − RUQ Dull / aching + in cirrhotic patients may be in cardicmyopathy − − >60% TS
>240 μg/L SF
Raised LFT
Hyperglycemia 		Ultrasound shows evidence of cirrhosis Extra intestinal findings:
  • hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis + − RUQ + −
Peritoneal causes Spontaneous bacterial peritonitis + − Diffuse + in cirrhotic patients ± − − Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
 Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Small intestine obstruction − − Diffuse − − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Volvulus − − Diffuse − − + − Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic − − RUQ + − − − N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic − − Flank pain − − − − N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia ± − Periumbilical − ± − − Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis ± ± Diffuse − + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm − − Diffuse − + − − N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage − − Diffuse − + − − N Anemia CT scan History of trauma
Gynaecological Causes Tubal causes Torsion of the cyst − − RLQ / LLQ − ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Acute salpingitis + ± RLQ / LLQ − − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Cyst rupture − − RLQ / LLQ − + ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy − − RLQ / LLQ − + − − N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Extra-abdominal causes Pulmonary disorders Pleural empyema + ± RUQ/Epigastric − − − − N
Cardiovascular disorders Myocardial Infarction − − Epigastric − + in cardiogenic shock − − N
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The differentials for pancreatic cancer mainly involve pathologies of the pancreas, bile duct, duodenum, lymphovascular tissue or metastasis from other sites. It is difficult to differentiate pancreatic cancer from other neoplasms as they all present with non specific constitutional symptoms. Hence, differentiation is primarily based on investigations:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]

Origin Disease Differentiation based on Investigations
Pancreas
Bile duct
Duodenum
Lymphovascular

tissue

Metastasis


References

  1. ↑ He XK, Ding Y, Sun LM (2017). "Contrast-enhanced endoscopic ultrasound for differential diagnosis of pancreatic cancer: an updated meta-analysis". Oncotarget. 8 (39): 66392–66401. doi:10.18632/oncotarget.18915. PMC 5630421. PMID 29029521.
  2. ↑ Steinman J, Zaheer A, Kluger MD, Remotti H, Hecht EM (2017). "Rare pancreatic tumors". Abdom Radiol (NY). doi:10.1007/s00261-017-1342-x. PMID 29022085.
  3. ↑ Ran L, Zhao W, Zhao Y, Bu H (2017). "Value of contrast-enhanced ultrasound in differential diagnosis of solid lesions of pancreas (SLP): A systematic review and a meta-analysis". Medicine (Baltimore). 96 (28): e7463. doi:10.1097/MD.0000000000007463. PMC 5515757. PMID 28700485.
  4. ↑ Kołodziejczyk E, Wejnarska K, Oracz G (2016). "Autoimmune pancreatitis in the paediatric population - review of the literature and own experience". Dev Period Med. 20 (4): 279–286. PMID 28216481.
  5. ↑ Zhu L, Xue HD, Liu W, Wang X, Sui X, Wang Q, Zhang D, Li P, Jin ZY (2017). "Enhancing pancreatic mass with normal serum CA19-9: key MDCT features to characterize pancreatic neuroendocrine tumours from its mimics". Radiol Med. 122 (5): 337–344. doi:10.1007/s11547-017-0734-x. PMID 28197876.
  6. ↑ Sano I, Katanuma A, Yane K, Kin T, Nagai K, Yamazaki H, Koga H, Kitagawa K, Yokoyama K, Ikarashi S, Takahashi K, Maguchi H, Omori Y, Shinohara T (2017). "Pancreatic Metastasis from Rectal Cancer that was Diagnosed by Endoscopic Ultrasonography-guided Fine Needle Aspiration (EUS-FNA)". Intern. Med. 56 (3): 301–305. doi:10.2169/internalmedicine.56.7213. PMC 5348454. PMID 28154274.
  7. ↑ Salaria SN, Shi C (2016). "Pancreatic Neuroendocrine Tumors". Surg Pathol Clin. 9 (4): 595–617. doi:10.1016/j.path.2016.05.006. PMID 27926362.
  8. ↑ Kawasaki K, Kawaguchi Y, Suzuki Y, Tanaka N (2016). "Renal neuroendocrine tumour and synchronous pancreas metastasis: histopathological diagnosis using prostatic acid phosphatase". BMJ Case Rep. 2016. doi:10.1136/bcr-2016-214759. PMID 27803081.
  9. ↑ Nassour I, Choti MA (2016). "Diagnosis and Treatment of Pancreatic Cystic Neoplasms". JAMA. 316 (12): 1326. doi:10.1001/jama.2016.9130. PMID 27673319.
  10. ↑ Javadi S, Menias CO, Korivi BR, Shaaban AM, Patnana M, Alhalabi K, Elsayes KM (2017). "Pancreatic Calcifications and Calcified Pancreatic Masses: Pattern Recognition Approach on CT". AJR Am J Roentgenol. 209 (1): 77–87. doi:10.2214/AJR.17.17862. PMID 28418702.
  11. ↑ Bergmann F (2016). "[Pancreatic acinar neoplasms : Comparative molecular characterization]". Pathologe (in German). 37 (Suppl 2): 191–195. doi:10.1007/s00292-016-0235-z. PMID 27807633.
  12. ↑ Cheng SK, Chuah KL (2016). "Metastatic Renal Cell Carcinoma to the Pancreas: A Review". Arch. Pathol. Lab. Med. 140 (6): 598–602. doi:10.5858/arpa.2015-0135-RS. PMID 27232353.
  13. ↑ Haage P, Schwartz CA, Scharwächter C (2016). "[Ductal adenocarcinoma and unusual differential diagnosis]". Radiologe (in German). 56 (4): 325–37. doi:10.1007/s00117-016-0090-1. PMID 27000276.
  14. ↑ Scialpi M, Reginelli A, D'Andrea A, Gravante S, Falcone G, Baccari P, Manganaro L, Palumbo B, Cappabianca S (2016). "Pancreatic tumors imaging: An update". Int J Surg. 28 Suppl 1: S142–55. doi:10.1016/j.ijsu.2015.12.053. PMID 26777740.
  15. ↑ Senosiain Lalastra C, Foruny Olcina JR (2015). "[Autoimmune pancreatitis]". Gastroenterol Hepatol (in Spanish; Castilian). 38 (9): 549–55. doi:10.1016/j.gastrohep.2015.01.006. PMID 25799073.
  16. ↑ Barbier L, Delpero JR (2014). "[Pancreatic tumours]". Rev Prat (in French). 64 (9): 1307–12. PMID 25638877.
  17. ↑ Díte P, Uvírová M, Bojková M, Novotný I, Dvorácková J, Kianicka B, Nechutová H, Dovrtelová L, Floreánová K, Martínek A (2014). "Differentiating autoimmune pancreatitis from pancreatic cancer". Minerva Gastroenterol Dietol. 60 (4): 247–53. PMID 25288201.
  18. ↑ Lalwani N, Mannelli L, Ganeshan DM, Shanbhogue AK, Dighe MK, Tiwari HA, Maximin S, Monti S, Ragucci M, Prasad SR (2015). "Uncommon pancreatic tumors and pseudotumors". Abdom Imaging. 40 (1): 167–80. doi:10.1007/s00261-014-0189-7. PMID 25063236.
  19. ↑ Dite P, Nechutova H, Uvirova M, Dvorackova J, Kianicka B, Martinek A (2014). "Autoimmune pancreatitis". Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 158 (1): 17–22. doi:10.5507/bp.2013.094. PMID 24572485.
  20. ↑ Mastoraki A, Tzortzopoulou A, Tsela S, Danias N, Sakorafas G, Smyrniotis V, Arkadopoulos N (2014). "Hereditary pancreatitis: dilemmas in differential diagnosis and therapeutic approach". J Gastrointest Cancer. 45 (1): 22–6. doi:10.1007/s12029-013-9559-6. PMID 24242859.
  21. ↑ Beyer G, Menzel J, Krüger PC, Ribback S, Lerch MM, Mayerle J (2013). "[Autoimmune pancreatitis]". Dtsch. Med. Wochenschr. (in German). 138 (46): 2359–70, quiz 2371–4. doi:10.1055/s-0033-1349475. PMID 24193862.
  22. ↑ Al-Hawary MM, Kaza RK, Azar SF, Ruma JA, Francis IR (2013). "Mimics of pancreatic ductal adenocarcinoma". Cancer Imaging. 13 (3): 342–9. doi:10.1102/1470-7330.2013.9012. PMC 3800430. PMID 24060833.
  23. ↑ Bednar F, Scheiman JM, McKenna BJ, Simeone DM (2013). "Breast cancer metastases to the pancreas". J. Gastrointest. Surg. 17 (10): 1826–31. doi:10.1007/s11605-013-2291-5. PMID 23918083.
  24. ↑ DiMagno MJ, DiMagno EP (2013). "Chronic pancreatitis". Curr. Opin. Gastroenterol. 29 (5): 531–6. doi:10.1097/MOG.0b013e3283639370. PMC 4387887. PMID 23852141.
  25. ↑ Berger AW, Seufferlein T, Kleger A (2017). "[Cystic pancreatic tumors: diagnostics and new biomarkers]". Chirurg (in German). 88 (11): 905–912. doi:10.1007/s00104-017-0493-1. PMID 28831506.
  26. ↑ Nougaret S, Mannelli L, Pierredon MA, Schembri V, Guiu B (2016). "Cystic pancreatic lesions: From increased diagnosis rate to new dilemmas". Diagn Interv Imaging. 97 (12): 1275–1285. doi:10.1016/j.diii.2016.08.017. PMID 27840080.
  27. ↑ Xu MM, Yin S, Siddiqui AA, Salem RR, Schrope B, Sethi A, Poneros JM, Gress FG, Genkinger JM, Do C, Brooks CA, Chabot JA, Kluger MD, Kowalski T, Loren DE, Aslanian H, Farrell JJ, Gonda TA (2017). "Comparison of the diagnostic accuracy of three current guidelines for the evaluation of asymptomatic pancreatic cystic neoplasms". Medicine (Baltimore). 96 (35): e7900. doi:10.1097/MD.0000000000007900. PMC 5585501. PMID 28858107.
  28. ↑ Dong J, Cong L, Zhang TP, Zhao YP (2016). "Pancreatic metastasis of renal cell carcinoma". HBPD INT. 15 (1): 30–8. PMID 26818541.

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