Pancreatic cancer differential diagnosis: Difference between revisions

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Revision as of 22:45, 20 November 2017

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 distinguished from other pancreatobiliary pathologies that cause abdominal pain and jaundice such as acute suppurative cholangitis, acute cholecystitis, cholelithiasis, chronic pancreatitis, primary biliary cirrhosis and primary sclerosing cholangitis. Pancreatic cancer must also be differentiated from other pancreatic pathologies such as 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 pain in the abdomen based on etiology			Disease	Clinical manifestations								Diagnosis		Comments
				Symptoms				Signs				Diagnosis
				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	Hyperbilirubinemia Leukocytosis	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	Increased liver enzymes Increased IgM, IgG4 Anti-neutrophil cytoplasmic antibody (p-ANCA) Anti-nuclear antibody (ANA) Anti-smooth muscle antibody (Anti-Sm) Anti-endothelial antibody Anti-cardiolipin antibody
			Cholelithiasis	±	−	RUQ/Epigastric	±	−	+	+	N to hyperactive for dislodged stone	Leukocytosis	Ultrasound shows gallstone	Murphy’s sign
			Pancreatic cancer	−	−	Epigastric	±	−	−	−	N	Elevated serum bilirubin (conjugated and total) Elevated alkaline phosphatase levels Elevated gamma-glutamyl transpeptidase levels Normal/elevated aspartate aminotransferase and alanine aminotransferase Serum amylase and/or lipase levels are normal/elevated mild normocytic normochromic anemia Thrombocytosis	CT shows morphological changes of the gland Destruction of the peripancreatic fat and loss of the sharp margins with surrounding structures Involvement of the regional lymph nodes and adjacent vasculature Pancreatic ductal dilatation Pancreatic atrophy Obstruction of the common bile duct (CBD) USG shows: ill defined hypoechoic mass is seen infiltrating into a bright pancreatic parenchyma EUS-guided fine needle aspiration biopsy (FNA) is the best modality for obtaining a tissue diagnosis.	Signs of metastatic disease 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) Involvement of other nodes in the cervical area
		Gastric causes	Gastrointestinal perforation	+	±	Diffuse	±	+	+	±		WBC> 10,000	Air under diaphragm in upright CXR
		Intestinal causes	Whipple's disease	±	−	Diffuse	±	±	−	−	N	Thrombocytopenia Hypoalbuminemia Small intestinal biopsy for Tropheryma whipplei	*Endoscopy is used to confirm diagnosis. Images used to find complications Chest and joint x-ray CT MRI Echocardiography	Extra intestinal findings: Uveitis Endocarditis Encephalitis Dementia Hepatosplenomegaly Arthritis Ascites
		Intestinal causes	Celiac disease	−	−	Diffuse	±, also dermatitis herpetiformis	−	−	−	Hyperactive (increased sounds)	IgA endomysial antibody IgA tissue transglutaminase antibody Anti-gliadin antibody
		Hepatic causes	Viral hepatitis	+	−	RUQ	+	−		+
			Liver masses	+	+ in Liver abscess	RUQ	±	+ in sepsis
			Budd-Chiari syndrome	±	−	RUQ		−
			Hemochromatosis	−	−	RUQ	±	+ 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		Biliary colic	−	−	RUQ	+	−	−	−	N	Increased bilirubin and alkaline phosphatase	Ultrasound	Nausea & vomiting

To review a comprehensive differential diagnosis of diseases presenting with abdominal pain, click here.

Differentiating Pancreatic Carcinoma on the basis of involved Organ

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 anatomic location:^[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	Diagnostic study of choice
Pancreas	Chronic pancreatitis Autoimmune pancreatitis Pseudocyst of pancreas Pancreatic cyst Neuroendocrine tumors of pancreas Gastrinoma VIPoma Somatostatinoma Insulinoma	Imaging: Non-contrast helical CT Biopsy findings Serum IgG4 levels for autoimmune pancreatitis For pancreatic NETs: Gastrin levels Somatostatin levels Insulin levels Serum electrolytes
Bile duct	Choledocholithiasis Gallstones (Cholelithiasis) Choledochal Cysts Cholangiocarcinoma Bile duct strictures Cholangitis Cholecystitis	Imaging: MRI MRCP USG bile duct ERCP Biopsy findings
Duodenum	Ampullary cancer Duodenal cancer	Imaging: MRI ERCP Upper GI Endoscopy Biopsy findings
Lymphovascular tissue	Abdominal aortic aneurysm Intestinal ischemia Lymphomas Gastric Pancreatic	Imaging: MRI MR Angiography CT Angiography Biopsy for lymphoma
Metastasis	Skin(Melanoma) Kidney Breast Colon Liver(Hepatocellular carcinoma) Stomach	Imaging: MRI PET scan CT Biopsy Specific markers for different cancers: HCC: AFP Breast: BRCA 1 and 2 Colon cancer: CEA Melanoma: S100

References

↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ Nassour I, Choti MA (2016). "Diagnosis and Treatment of Pancreatic Cystic Neoplasms". JAMA. 316 (12): 1326. doi:10.1001/jama.2016.9130. PMID 27673319.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ Barbier L, Delpero JR (2014). "[Pancreatic tumours]". Rev Prat (in French). 64 (9): 1307–12. PMID 25638877.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ DiMagno MJ, DiMagno EP (2013). "Chronic pancreatitis". Curr. Opin. Gastroenterol. 29 (5): 531–6. doi:10.1097/MOG.0b013e3283639370. PMC 4387887. PMID 23852141.
↑ 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.
↑ 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.
↑ 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.
↑ Dong J, Cong L, Zhang TP, Zhao YP (2016). "Pancreatic metastasis of renal cell carcinoma". HBPD INT. 15 (1): 30–8. PMID 26818541.

Template:WH Template:WS

[pmid29029521-1] 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.

[pmid29022085-2] 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.

[pmid28700485-3] 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.

[pmid28216481-4] 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.

[pmid28197876-5] 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.

[pmid28154274-6] 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.

[pmid27926362-7] 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.

[pmid27803081-8] 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.

[pmid27673319-9] Nassour I, Choti MA (2016). "Diagnosis and Treatment of Pancreatic Cystic Neoplasms". JAMA. 316 (12): 1326. doi:10.1001/jama.2016.9130. PMID 27673319.

[pmid28418702-10] 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.

[pmid27807633-11] 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.

[pmid27232353-12] 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.

[pmid27000276-13] 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.

[pmid26777740-14] 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.

[pmid25799073-15] 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.

[pmid25638877-16] Barbier L, Delpero JR (2014). "[Pancreatic tumours]". Rev Prat (in French). 64 (9): 1307–12. PMID 25638877.

[pmid25288201-17] 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.

[pmid25063236-18] 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.

[pmid24572485-19] 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.

[pmid24242859-20] 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.

[pmid24193862-21] 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.

[pmid24060833-22] 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.

[pmid23918083-23] 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.

[pmid23852141-24] DiMagno MJ, DiMagno EP (2013). "Chronic pancreatitis". Curr. Opin. Gastroenterol. 29 (5): 531–6. doi:10.1097/MOG.0b013e3283639370. PMC 4387887. PMID 23852141.

[pmid28831506-25] 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.

[pmid27840080-26] 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.

[pmid28858107-27] 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.

[pmid26818541-28] 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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@@ Line 4: / Line 4: @@
 ==Overview==
-[[Pancreatic cancer]] must be distinguished from other pancreatobiliary pathologies that cause [[abdominal pain]] and [[jaundice]] such as acute [[Pus|suppurative]] [[cholangitis]], [[Cholecystitis|acute cholecystitis]], [[Gallstone disease|cholelithiasis]], [[chronic pancreatitis]], [[primary biliary cirrhosis]] and [[primary sclerosing cholangitis]]. [[Pancreatic cancer]] must also be differentiated from other [[Pancreas|pancreatic]] pathologies such as  [[autoimmune pancreatitis]], [[pancreatic pseudocyst]], and neuroendocrine tumors of the pancreas. Pathologies of the [[bile duct]] and [[duodenum]] such as [[Choledocholithiasis]], [[Gallstone disease|gallstones]] ([[Gallstone disease|Cholelithiasis]]), [[Bile duct cyst|Choledochal Cysts]], [[Cholangiocarcinoma]], [[Bile duct]] [[Stenosis|strictures]] and [[Ampulla of Vater|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 aneurysm|abdominal aortic aneurysms]] may also mimic [[pancreatic cancer]].
+[[Pancreatic cancer]] must be distinguished from other pancreatobiliary pathologies that cause [[abdominal pain]] and [[jaundice]] such as acute [[Pus|suppurative]] [[cholangitis]], [[Cholecystitis|acute cholecystitis]], [[Gallstone disease|cholelithiasis]], [[chronic pancreatitis]], [[primary biliary cirrhosis]] and [[primary sclerosing cholangitis]]. [[Pancreatic cancer]] must also be differentiated from other [[Pancreas|pancreatic]] pathologies such as  [[autoimmune pancreatitis]], [[pancreatic pseudocyst]], and neuroendocrine tumors of the pancreas. Pathologies of the [[bile duct]] and [[duodenum]] such as [[Choledocholithiasis]], [[Gallstone disease|gallstones]] ([[Gallstone disease|cholelithiasis]]), [[Bile duct cyst|choledochal cysts]], [[Cholangiocarcinoma]], [[Bile duct]] [[Stenosis|strictures]] and [[Ampulla of Vater|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 aneurysm|abdominal aortic aneurysms]] may also mimic [[pancreatic cancer]].
 ==Differentiating Pancreatic Cancer from other Diseases==
@@ Line 13: / Line 13: @@
 |
 {| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
-! colspan="3" rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Classification of pain in the abdomen based on etiology
+! colspan="3" rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Classification of pain in the abdomen based on etiology
-! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Disease
+! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease
-! colspan="8" align="center" style="background:#4479BA; color: #FFFFFF;" |Clinical manifestations
+! colspan="8" style="background:#4479BA; color: #FFFFFF;" align="center" |Clinical manifestations
-! colspan="2" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Diagnosis
+! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis
-! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Comments
+! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments
 |-
-! colspan="4" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Symptoms
+! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Symptoms
-! colspan="4" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Signs
+! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs
 |-
-! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Fever
+! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Rigors and chills
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Rigors and chills
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Abdominal Pain
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Jaundice
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Hypo-
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo-
 tension
-! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Guarding
+! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Guarding
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Rebound Tenderness
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Bowel sounds
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds
-! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Lab Findings
+! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
-! align="center" style="background:#4479BA; color: #FFFFFF;" |Imaging
+! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
 |-
-! rowspan="18" align="center" style="background:#4479BA; color: #FFFFFF;" |Abdominal causes
+! rowspan="18" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal causes
 ! colspan="1" rowspan="17" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Inflammatory causes
 ! rowspan="8" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pancreato-biliary disorders
@@ Line 77: / Line 77: @@
 * [[Hyperbilirubinemia]]
 * [[Leukocytosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows gallstone and evidence of inflammation
+| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows [[gallstone]] and evidence of inflammation
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Murphy's sign|Murphy’s sign]]
 |-
@@ Line 173: / Line 173: @@
 * Involvement of other [[Lymph node|nodes]] in the [[cervical]] area
 |-
-! style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gastric causes
+! style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastric]] causes
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastrointestinal perforation]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
@@ Line 187: / Line 187: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 |-
-! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intestinal causes
+! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Intestinal]] causes
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Whipple's disease]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
@@ Line 232: / Line 232: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 |-
-! rowspan="5" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hepatic causes
+! rowspan="5" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatic]] causes
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatitis|Viral hepatitis]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
@@ Line 281: / Line 281: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |>60% TS<br> >240 μg/L SF <br>Raised LFT <br>Hyperglycemia
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" |>60% TS<br> >240 μg/L SF <br>Raised LFT <br>[[Hyperglycemia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Ultrasound shows evidence of cirrhosis
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Ultrasound shows evidence of [[cirrhosis]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Extra intestinal findings:
-* hyperpigmentation
+* [[hyperpigmentation]]
-* Diabetes mellitus
+* [[Diabetes mellitus]]
-* Arthralgia
+* [[Arthralgia]]
-* Impotence in males
+* [[Impotence]] in males
-* Cardiomyopathy
+* [[Cardiomyopathy]]
-* Atherosclerosis
+* [[Atherosclerosis]]
-* Hypopituitarism
+* [[Hypopituitarism]]
-* Hypothyroidism
+* [[Hypothyroidism]]
-* Extrahepatic cancer
+* [[Extrahepatic cholangiocarcinoma|Extrahepatic]] cancer
-* Prone to specific infections
+* Prone to specific [[infections]]
 |-
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cirrhosis|Cirrhosis]]
@@ Line 308: / Line 308: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 |-
-! style="padding: 5px 5px; background: #DCDCDC;" align="center" | Peritoneal causes
+! style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Peritoneal]] causes
 | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Spontaneous bacterial peritonitis]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
@@ Line 351: / Line 351: @@
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Diagnostic study of choice
 |-
-| style="background:#DCDCDC; + " | '''Pancreas'''
+| style="background:#DCDCDC; + " | '''[[Pancreas]]'''
 |
 * [[Chronic pancreatitis]]
@@ Line 370: / Line 370: @@
 ** [[Somatostatin]] levels
 ** [[Insulin]] levels
-** Serum electrolytes
+** Serum [[Electrolyte|electrolytes]]
 |-
 | style="background:#DCDCDC; + " | '''Bile duct'''
@@ Line 389: / Line 389: @@
 * [[Biopsy]] findings
 |-
-| style="background:#DCDCDC; + " | '''Duodenum'''
+| style="background:#DCDCDC; + " | '''[[Duodenum]]'''
 |
-* Ampullary cancer
+* [[Ampulla|Ampullary cancer]]
 * [[Duodenum|Duodenal]] cancer
 |
@@ Line 415: / Line 415: @@
 * [[Biopsy]] for [[lymphoma]]
 |-
-| style="background:#DCDCDC; + " | '''Metastasis'''
+| style="background:#DCDCDC; + " | '''[[Metastasis]]'''
 |
 * [[Skin]]([[Melanoma]])