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* Chronic groaning pain
* Chronic groaning pain
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* [[Asthenia]] and [[depression]]<ref name="pmid15960930">{{cite journal |vauthors=Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX |title=Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage |journal=Clin Transl Oncol |volume=7 |issue=5 |pages=189–97 |date=June 2005 |pmid=15960930 |doi= |url=}}</ref><ref name="pmid1589710">{{cite journal |vauthors=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 |date=April 1992 |pmid=1589710 |doi= |url=}}</ref><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 |date=July 1985 |pmid=4005804 |doi= |url=}}</ref>
* [[Asthenia]] and [[depression]]<ref name="pmid15960930">{{cite journal |vauthors=Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX |title=Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage |journal=Clin Transl Oncol |volume=7 |issue=5 |pages=189–97 |date=June 2005 |pmid=15960930 |doi= |url=}}</ref><ref name="pmid1589710">{{cite journal |vauthors=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 |date=April 1992 |pmid=1589710 |doi= |url=}}</ref><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 |date=July 1985 |pmid=4005804 |doi= |url=}}</ref><ref name="pmid159609302">{{cite journal |vauthors=Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX |title=Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage |journal=Clin Transl Oncol |volume=7 |issue=5 |pages=189–97 |date=June 2005 |pmid=15960930 |doi= |url=}}</ref>


* [[Jaundice]]
* [[Jaundice]]

Revision as of 20:14, 24 January 2019

Small intestine cancer Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Qurrat-ul-ain Abid, M.D.[2]Parminder Dhingra, M.D. [3]

Overview

Small intestine cancer must be differentiated from Crohn's disease, intestinal tuberculosis, ulcerative colitis, large intestine cancer, peptic ulcer disease, and irritable bowel syndrome (IBS).

Differential Diagnosis

tab

Diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms
Lab Findings Imaging Histopathology
Constipation/Diarrhea Blood in stool Abdominal pain Other symptoms Anemia Tumor marker Endoscopy CT scan Other diagnostic study
Adenocarcinoma[1]

and/or

+
  • Diffuse abdominal pain +/-
 +
  • Different grades of differentiation of glandular structures
    • Sheets or cords of malignant cells,
    • Cellular atypia, pleomorphism
    • High mitotic rate
  • Necrotic debris in glandular lumina
  • Desmoplastic reaction (sign of invasion)
Carcinoids[2][3][4][5][6] +/-
  • Abdominal pain
 +
  • Infiltrating, ulcerating or fungating lesions in the wall of colon
  • Well-defined single or multiple lesions
  • Round or ovoid in shape
  • Variable in size ranges between 2-5 cm
  • PET scan 11C-5-hydroxytryptophan (11C-5-HTP): Deetects metastasis
  • MRI:
    • Nodular mass originating from the bowel wall or regional uniform bowel wall thickening with moderate intense enhancement on post gadolinium T1-weighted fat-suppressed images
    • Mesenteric metastases presents as nodular masses with mesenteric stranding
    • Liver metastases may show hypointense precontrast T1- and hyperintense T2-weighted images
    • Liver metastases are commonly hypervascular
  • Ki-67 index
  • Solid or spongy nests of cells accentuated by neatly outlined luminal spaces
  • Peripheral nuclear palisading
  • Granular eosinophilic cytoplasm.
Intestinal Lymphoma[7][8]
  • Normal
 +/-
  • Depending on location
  • Weight loss
 +
  • Non-Hodgkin’s lymphomas: CD-20
  • Polypoid or ulcerated mass, intramural lesion, aphthous ulcer, stricture, extraluminal mass, or diffuse, multiple polypoid lesions
  • CT scan: polypoid mass, circumferential-cavitary lesions, focal mucosal nodularity, diffuse ulcerative or nodular lesions, regional lymph node involvement
  • Biopsy
Gastrointestinal Stromal Tumors (GIST)[9][10][11][12][13] +/- +/-
  • No pain
  • Mostly asymptomatic
  • Are discovered incidentally
  • Non-specific symptoms
  • Early satiety and bloating
 +/-
Peutz-Jeghers syndrome[16][17][18][19][20]

and/or

+
  • Abdominal pain
 +
  • N/A
Juvenile Polyposis Coli[21][22][23][24][25] +
  • Diffuse abdominal pain
 +
  • N/A
  • Barium study: Multiple polyps in GI tract
  • Stool DNA test: SMAD4 or BMPR1A
  • Diagnose if any of the following positive:
    • More than five juvenile polyps of the colorectum
    • Multiple juvenile polyps throughout the GI tract
    • Any number of juvenile polyps and a family history of juvenile polyposis
    • Heterozygous pathogenic variant in SMAD4 or BMPR1A
  • Numerous cystic and dilated crypts or glands with inspissated mucin and intraluminal neutrophils
  • Lamina propria edematous with associated lymphocytes, plasma cells, eosinophils and neutrophils
  • Filiform, multilobated forms with increased glandular-to-stroma ratio in nonclassic or atypical polyps
  • Areas of conventional dysplasia
  • If any of the following positive:
    • More than five juvenile polyps of the colorectum
    • Multiple juvenile polyps throughout the GI tract
    • Any number of juvenile polyps and a family history of juvenile polyposis
    • Heterozygous pathogenic variant in SMAD4 or BMPR1A
Kaposi's sarcoma[26] +
  • Diffuse abdominal pain
 +
  • Localized purpuric lesion
  • N/A
  • Biopsy
Arteriovenous malformation[27]
  • Normal
 +
  • No pain
  • N/A
 +
  • N/A
  • Bright red, flat lesions
  • Rarely, polypoid
  • N/A
  • N/A
  • Aberrant vessels with thickened, hypertrophic walls in the mucosa and the submucosa.
  • Arteries directly connected to veins without capillary beds
  • Accidental fining
Infectious colitis[28] +
  • Diffuse abdominal
 -
  • N/A
  • N/A
  • N/A
  • Stool culture
Hamartoma[29] +
  • Depending on location
 -
  • S100 (mucosal Schwann cell hamartoma (MSCH))
  • Large polypoid mass
  • Biopsy: Proliferation of bland spindle cells in the lamina propria (mucosal Schwann cell hamartoma (MSCH))
  • poorly circumscribed, short fascicles of uniform spindle cells replacing the colonic lamina propria, separating and entrapping the crypts
  • The nuclei are bland and mostly uniform, occasional larger nuclei are found. The cytoplasmic borders are indistinct
  • Involvement of mucosa but never the submucosa
  • Biopsy
Ulcerative colitis[30] + +
  • N/A
  • N/A
  • N/A
  • Mucosal and submucosal inflammation[30]
  • Hemorrhage or inflammatory polymorphonuclear cells aggregate in the lamina propria
  • Distorted crypts
  • Crypt abscess
  • Endoscopy and a mucosal biopsy[31]
Crohn's disease[30] +
  • Lain in RQ
 +
  • N/A
  • Discontinuous lesions
  • Strictures
  • Linear ulcerations
  • N/A
  • N/A
  • Transmural pattern of inflammation
  • Mucosal damage
  • Focal infiltration of leukocytes into the epithelium
  • Granulomas
  • Endoscopy and a mucosal biopsy
Irritable bowel syndrome[32]

and/or

+
  • Diffuse abdominal pain
 -
  • N/A
  • Not recommended
  • N/A
  • N/A
Bowel endometriosis[33]

and/or

+
  • Pelvic pain
  • Dyschezia
  • Tenesmus
 +
  • N/A
  • N/A
  • N/A
  • Transvaginal ultrasonography: heterogeneous, hypoechoic, spiculated mass
  • Barium enema: Extrinsic mass compressing the bowel, fine crenulation of the mucosa, bowel strictures at the rectosigmoid junction
  • T1-weighted or fat-suppression T1-weighted MRIs: Contrast enhanced mass or hyperintense foci, hemorrhagic foci or hyperintense cavities
  • N/A
  • Transvaginal ultrasonography
Intestinal tuberculosis[34] Chronic diarrhea +/- +
  • Fever[35]
  • Fatigue,
  • Weight loss
  • Anorexia
  • Night sweats
  • Bowel obstruction[36]
  • Abdominal distension
  • Lymph node enlargement
 +
  • N/A
  • To get sample for histolopathology and culture
  • Forms on endoscopy:
    • Hypertrophic
    • Ulcerative
  • Concentric thickening at the site of lesion with proximal intestinal dilatation[38]
  • asymmetric thickening of the intestinal wall
  • Lymphadenopathy
  • Thickening of the peritoneum
  • Ascites
Peptic ulcer disease +/- + Melena + +
  • N/A
  • Endoscopic visualization of ulcer[45]
Pancreatic cancer +
  • Chronic groaning pain
Gastric cancer

References

  1. ↑ Secco GB, Fardelli R, Campora E, Lapertosa G, Gentile R, Zoli S, Prior C (1994). "Primary mucinous adenocarcinomas and signet-ring cell carcinomas of colon and rectum". Oncology. 51 (1): 30–4. doi:10.1159/000227306. PMID 8265100.
  2. ↑ Chung TP, Hunt SR (May 2006). "Carcinoid and neuroendocrine tumors of the colon and rectum". Clin Colon Rectal Surg. 19 (2): 45–8. doi:10.1055/s-2006-942343. PMC 2780103. PMID 20011309.
  3. ↑ Diagnostics: Biochemical Markers, Imaging, and Approach. National cancer institute. http://www.cancer.gov/types/gi-carcinoid-tumors/hp/gi-carcinoid-treatment-pdq
  4. ↑ Rindi G, Falconi M, Klersy C, Albarello L, Boninsegna L, Buchler MW, Capella C, Caplin M, Couvelard A, Doglioni C, Delle Fave G, Fischer L, Fusai G, de Herder WW, Jann H, Komminoth P, de Krijger RR, La Rosa S, Luong TV, Pape U, Perren A, Ruszniewski P, Scarpa A, Schmitt A, Solcia E, Wiedenmann B (May 2012). "TNM staging of neoplasms of the endocrine pancreas: results from a large international cohort study". J. Natl. Cancer Inst. 104 (10): 764–77. doi:10.1093/jnci/djs208. PMID 22525418.
  5. ↑ Fang C, Wang W, Zhang Y, Feng X, Sun J, Zeng Y, Chen Y, Li Y, Chen M, Zhou Z, Chen J (June 2017). "Clinicopathologic characteristics and prognosis of gastroenteropancreatic neuroendocrine neoplasms: a multicenter study in South China". Chin J Cancer. 36 (1): 51. doi:10.1186/s40880-017-0218-3. PMC 5480192. PMID 28637502.
  6. ↑ Signs and symptoms of carcinoid syndrome. National Cancer Institute. http://www.cancer.gov/types/gi-carcinoid-tumors/patient/gi-carcinoid-treatment-pdq
  7. ↑ Quayle FJ, Lowney JK (May 2006). "Colorectal lymphoma". Clin Colon Rectal Surg. 19 (2): 49–53. doi:10.1055/s-2006-942344. PMC 2780105. PMID 20011310.
  8. ↑ Quayle, Frank; Lowney, Jennifer (2006). "Colorectal Lymphoma". Clinics in Colon and Rectal Surgery. 19 (2): 049–053. doi:10.1055/s-2006-942344. ISSN 1531-0043.
  9. ↑ Niazi AK, Kaley K, Saif MW (May 2014). "Gastrointestinal stromal tumor of colon: a case report and review of literature". Anticancer Res. 34 (5): 2547–50. PMID 24778074.
  10. ↑ Niazi AK, Kaley K, Saif MW (May 2014). "Gastrointestinal stromal tumor of colon: a case report and review of literature". Anticancer Res. 34 (5): 2547–50. PMID 24778074.
  11. ↑ Medeiros F, Corless CL, Duensing A, Hornick JL, Oliveira AM, Heinrich MC, Fletcher JA, Fletcher CD (July 2004). "KIT-negative gastrointestinal stromal tumors: proof of concept and therapeutic implications". Am. J. Surg. Pathol. 28 (7): 889–94. PMID 15223958.
  12. ↑ Kamiyama Y, Aihara R, Nakabayashi T, Mochiki E, Asao T, Kuwano H, Oriuchi N, Endo K (November 2005). "18F-fluorodeoxyglucose positron emission tomography: useful technique for predicting malignant potential of gastrointestinal stromal tumors". World J Surg. 29 (11): 1429–35. doi:10.1007/s00268-005-0045-6. PMID 16222452.
  13. ↑ Miettinen M, Sobin LH, Lasota J (January 2005). "Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up". Am. J. Surg. Pathol. 29 (1): 52–68. PMID 15613856.
  14. ↑ Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, Miettinen M, O'Leary TJ, Remotti H, Rubin BP, Shmookler B, Sobin LH, Weiss SW (April 2002). "Diagnosis of gastrointestinal stromal tumors: a consensus approach". Int. J. Surg. Pathol. 10 (2): 81–9. doi:10.1177/106689690201000201. PMID 12075401.
  15. ↑ Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, Miettinen M, O'Leary TJ, Remotti H, Rubin BP, Shmookler B, Sobin LH, Weiss SW (April 2002). "Diagnosis of gastrointestinal stromal tumors: a consensus approach". Int. J. Surg. Pathol. 10 (2): 81–9. doi:10.1177/106689690201000201. PMID 12075401.
  16. ↑ Zhong ME, Niu BZ, Ji WY, Wu B (June 2016). "Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for Peutz-Jeghers syndrome with synchronous rectal cancer". World J. Gastroenterol. 22 (22): 5293–6. doi:10.3748/wjg.v22.i22.5293. PMID 27298573.
  17. ↑ Kopacova, Marcela; Tacheci, Ilja; Rejchrt, Stanislav; Bures, Jan (2009). "Peutz-Jeghers syndrome: Diagnostic and therapeuticapproach". World Journal of Gastroenterology. 15 (43): 5397. doi:10.3748/wjg.15.5397. ISSN 1007-9327.
  18. ↑ Giardiello, F; Trimbath, J (2006). "Peutz-Jeghers Syndrome and Management Recommendations". Clinical Gastroenterology and Hepatology. 4 (4): 408–415. doi:10.1016/j.cgh.2005.11.005. ISSN 1542-3565.
  19. ↑ Beggs, A. D.; Latchford, A. R.; Vasen, H. F. A.; Moslein, G.; Alonso, A.; Aretz, S.; Bertario, L.; Blanco, I.; Bulow, S.; Burn, J.; Capella, G.; Colas, C.; Friedl, W.; Moller, P.; Hes, F. J.; Jarvinen, H.; Mecklin, J.-P.; Nagengast, F. M.; Parc, Y.; Phillips, R. K. S.; Hyer, W.; Ponz de Leon, M.; Renkonen-Sinisalo, L.; Sampson, J. R.; Stormorken, A.; Tejpar, S.; Thomas, H. J. W.; Wijnen, J. T.; Clark, S. K.; Hodgson, S. V. (2010). "Peutz-Jeghers syndrome: a systematic review and recommendations for management". Gut. 59 (7): 975–986. doi:10.1136/gut.2009.198499. ISSN 0017-5749.
  20. ↑ Kopacova, Marcela; Tacheci, Ilja; Rejchrt, Stanislav; Bures, Jan (2009). "Peutz-Jeghers syndrome: Diagnostic and therapeuticapproach". World Journal of Gastroenterology. 15 (43): 5397. doi:10.3748/wjg.15.5397. ISSN 1007-9327.
  21. ↑ Grotsky HW, Rickert RR, Smith WD, Newsome JF (March 1982). "Familial juvenile polyposis coli. A clinical and pathologic study of a large kindred". Gastroenterology. 82 (3): 494–501. PMID 7054044.
  22. ↑ Brosens LA, Langeveld D, van Hattem WA, Giardiello FM, Offerhaus GJ (November 2011). "Juvenile polyposis syndrome". World J. Gastroenterol. 17 (44): 4839–44. doi:10.3748/wjg.v17.i44.4839. PMC 3235625. PMID 22171123.
  23. ↑ Latchford AR, Neale K, Phillips RK, Clark SK (October 2012). "Juvenile polyposis syndrome: a study of genotype, phenotype, and long-term outcome". Dis. Colon Rectum. 55 (10): 1038–43. doi:10.1097/DCR.0b013e31826278b3. PMID 22965402.
  24. ↑ Latchford AR, Neale K, Phillips RK, Clark SK (October 2012). "Juvenile polyposis syndrome: a study of genotype, phenotype, and long-term outcome". Dis. Colon Rectum. 55 (10): 1038–43. doi:10.1097/DCR.0b013e31826278b3. PMID 22965402.
  25. ↑ Latchford AR, Neale K, Phillips RK, Clark SK (October 2012). "Juvenile polyposis syndrome: a study of genotype, phenotype, and long-term outcome". Dis. Colon Rectum. 55 (10): 1038–43. doi:10.1097/DCR.0b013e31826278b3. PMID 22965402.
  26. ↑ Arora M, Goldberg EM (July 2010). "Kaposi sarcoma involving the gastrointestinal tract". Gastroenterol Hepatol (N Y). 6 (7): 459–62. PMC 2933764. PMID 20827371.
  27. ↑ Lee HH, Kwon HM, Gil S, Kim YS, Cho M, Seo KJ, Chae HS, Cho YS (2017). "Endoscopic resection of asymptomatic, colonic, polypoid arteriovenous malformations: Two case reports and a literature review". Saudi J Gastroenterol. 23 (1): 67–70. doi:10.4103/1319-3767.199111. PMC 5329980. PMID 28139503.
  28. ↑ DuPont HL (January 2012). "Approach to the patient with infectious colitis". Curr. Opin. Gastroenterol. 28 (1): 39–46. doi:10.1097/MOG.0b013e32834d3208. PMID 22080825.
  29. ↑ Cauchin E, Touchefeu Y, Matysiak-Budnik T (September 2015). "Hamartomatous Tumors in the Gastrointestinal Tract". Gastrointest Tumors. 2 (2): 65–74. doi:10.1159/000437175. PMC 4668787. PMID 26672891.
  30. ↑ 30.0 30.1 30.2 30.3 30.4 Fakhoury M, Negrulj R, Mooranian A, Al-Salami H (2014). "Inflammatory bowel disease: clinical aspects and treatments". J Inflamm Res. 7: 113–20. doi:10.2147/JIR.S65979. PMC 4106026. PMID 25075198.
  31. ↑ Collins P, Rhodes J (August 2006). "Ulcerative colitis: diagnosis and management". BMJ. 333 (7563): 340–3. doi:10.1136/bmj.333.7563.340. PMC 1539087. PMID 16902215.
  32. ↑ Iwańczak B, Iwańczak F (August 2017). "[Functional gastrointestinal disorders in children and adolescents. The Rome IV criteria]". Pol. Merkur. Lekarski (in Polish). 43 (254): 75–82. PMID 28875974.
  33. ↑ Wolthuis AM, Meuleman C, Tomassetti C, D'Hooghe T, de Buck van Overstraeten A, D'Hoore A (November 2014). "Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team". World J. Gastroenterol. 20 (42): 15616–23. doi:10.3748/wjg.v20.i42.15616. PMC 4229526. PMID 25400445.
  34. ↑ Bhansali SK (April 1977). "Abdominal tuberculosis. Experiences with 300 cases". Am. J. Gastroenterol. 67 (4): 324–37. PMID 879148.
  35. ↑ Das P, Shukla HS (December 1976). "Clinical diagnosis of abdominal tuberculosis". Br J Surg. 63 (12): 941–6. PMID 1009343.
  36. ↑ Petrosyan M, Mason RJ (February 2006). "Tuberculous enteritis presenting as small-bowel obstruction". Clin. Gastroenterol. Hepatol. 4 (2): xxiii. PMID 16469667.
  37. ↑ Alvares JF, Devarbhavi H, Makhija P, Rao S, Kottoor R (April 2005). "Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital". Endoscopy. 37 (4): 351–6. doi:10.1055/s-2005-861116. PMID 15824946.
  38. ↑ Balthazar EJ, Gordon R, Hulnick D (March 1990). "Ileocecal tuberculosis: CT and radiologic evaluation". AJR Am J Roentgenol. 154 (3): 499–503. doi:10.2214/ajr.154.3.2106212. PMID 2106212.
  39. ↑ Rathi P, Gambhire P (February 2016). "Abdominal Tuberculosis". J Assoc Physicians India. 64 (2): 38–47. PMID 27730779.
  40. ↑ Ramakrishnan K, Salinas RC (October 2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071.
  41. ↑ Lu CL, Chang SS, Wang SS, Chang FY, Lee SD (July 2004). "Silent peptic ulcer disease: frequency, factors leading to "silence," and implications regarding the pathogenesis of visceral symptoms". Gastrointest. Endosc. 60 (1): 34–8. PMID 15229422.
  42. ↑ Chung KT, Shelat VG (January 2017). "Perforated peptic ulcer - an update". World J Gastrointest Surg. 9 (1): 1–12. doi:10.4240/wjgs.v9.i1.1. PMC 5237817. PMID 28138363.
  43. ↑ Cotton PB, Shorvon PJ (May 1984). "Analysis of endoscopy and radiography in the diagnosis, follow-up and treatment of peptic ulcer disease". Clin Gastroenterol. 13 (2): 383–403. PMID 6378443.
  44. ↑ Tonolini M, Ierardi AM, Bracchi E, Magistrelli P, Vella A, Carrafiello G (October 2017). "Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis". Insights Imaging. 8 (5): 455–469. doi:10.1007/s13244-017-0562-5. PMC 5621988. PMID 28677101.
  45. ↑ Cotton PB, Shorvon PJ (May 1984). "Analysis of endoscopy and radiography in the diagnosis, follow-up and treatment of peptic ulcer disease". Clin Gastroenterol. 13 (2): 383–403. PMID 6378443.
  46. ↑ Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX (June 2005). "Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage". Clin Transl Oncol. 7 (5): 189–97. PMID 15960930.
  47. ↑ Bakkevold KE, Arnesjø B, Kambestad B (April 1992). "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". Scand. J. Gastroenterol. 27 (4): 317–25. PMID 1589710.
  48. ↑ Kalser MH, Barkin J, MacIntyre JM (July 1985). "Pancreatic cancer. Assessment of prognosis by clinical presentation". Cancer. 56 (2): 397–402. PMID 4005804.
  49. ↑ Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX (June 2005). "Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage". Clin Transl Oncol. 7 (5): 189–97. PMID 15960930.

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