pancreatic cancer is diagnosed in over 56,000 people in the US each year. 85% of these are adenocarcinomas.23 Early diagnosis can be difficult because symptoms may be absent or vague in the early stages of the disease. Thus only ∼15–20% of patients have tumours amenable to surgical resection at presentation. The overall five‐year survival rate is less than 10%, but it is higher for patients diagnosed at earlier stages.
The predominant risk factor is age, although there is a relationship to cigarette smoking. Genetic and general medical conditions such as familial breast cancer, hereditary pancreatitis, chronic pancreatitis, and diabetes are also risk factors.
Clinical features
Cancer of the head of the pancreas presents with jaundice, often with epigastric or back discomfort. Later in the clinical course, other symptoms of cholestatic jaundice such as itching, pale stools, and dark urine occur. Anorexia and weight loss are common. Tumours of the body and tail of the pancreas present more insidiously and are often recognized only when distal spread of the disease has occurred.
Figure 21.3 Hypoenhancing lesion with a central cystic component at the pancreatic neck with associated upstream mild dilatation of the pancreatic duct.
Diagnosis of pancreatic cancer
Following an initial assessment with blood work, tumour marker CA19‐9, CT scan, and ultrasonography are typically the first imaging steps. Ultrasound may reveal biliary dilation in the setting of a pancreatic head cancer but is otherwise insensitive to the presence of a pancreatic mass in many cases. CT scan is a much more accurate imaging modality and also has the benefit of providing vascular staging information.
CT scanning may also help identify tumour expansion outside the confines of the gland, such as a metastatic tumour in the liver or adjacent lymph nodes (Figure 21.3). Diagnosis is now most commonly confirmed by endoscopic ultrasound with fine‐needle biopsy. ERCP may also be indicated for biliary stent placement in the setting of obstructive jaundice.
Management of pancreatic cancer
Surgery alone offers the hope of cure and, even if performed, offers a five‐year survival rate of only 20%. Adjuvant therapy with a fluorouracil‐based chemotherapy protocol (e.g. FOLFIRINOX) is the first‐line systemic therapy. In patients with unresectable disease, chemoradiation can be used. Gemcitabine is the standard of care in locally advanced unresectable pancreatic adenocarcinoma, and the agent may also be used as part of a combined chemotherapy protocol.24
Despite significant ongoing advances in efficacy and tolerability of treatment approaches, many patients with pancreatic adenocarcinoma, including those who could be curable, are not referred for multidisciplinary oncologic evaluation. In general, our recommendation is that even in the elderly or chronically ill patient who may decline treatment, a formal consultation with an oncology team is important to ensure that patients and families are aware of all treatment options, ranging from potentially curative to palliative.
Key points
Although pancreatic morphological change occurs in the elderly, it may not correlate with pancreatic dysfunction.
Acute pancreatitis associated with gallstone disease is the commonest cause of acute pancreatitis in the elderly.
Pancreatic cysts are found incidentally in up to 40% of cross‐sectional imaging scans, and referral to gastroenterology is reasonable for cysts >1 cm in size.
Pancreatic cancer remains a challenging condition to treat, but treatment options are expanding rapidly, and elderly patients should be offered formal oncologic consultation.
References
1 1. Laugier R, Sarles H. The pancreas. Clin Gastroenterol. 1985; 14:749–56.
2 2. Gapp J, Hall AG, Walters RW, Jahann D, Kassim T, Reddymasu S. Trends and outcomes of hospitalizations related to acute pancreatitis: Epidemiology from 2001 to 2014 in the United States. Pancreas. 2019; 48(4): 548–54.
3 3. Lankisch PG, Droge M, Gotteslaben F. Drug induced acute pancreatitis: incidence and severity. Gut. 1995; 37:565–7.
4 4. Chari ST, Smyrk TC, Levy MJ, et al. Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience. Clin Gastroenterol Hepatol. 2006; 4:1010–6.
5 5. Sah RP, Dawra RK, Saluja AK. New insights into the pathogenesis of pancreatitis. Current Expert Rev Gastroenterol Hepatol. Opinion Gastroenterology. 2013; 29(5):523–30.
6 6. Skouras C, Hayes AJ, Williams L, et al. Early organ dysfunction affects long‐term survival in acute pancreatitis patients. HPB (Oxford). 2014; 16(9):789–96.
7 7. Ranson JHC, Rifkind KM, Roscs DF, et al. Objective early identification of severe acute pancreatitis. Am J Gastroenterol. 1974; 51:443–51.
8 8. Blamey SL, Imrie CW, O’Neil J, et al. Prognostic factors in acute pancreatitis. Gut. 1984; 25:1340–6.
9 9. Papachristou GI, Muddana V, Yadav D, et al. Comparison of BISAP, Ranson’s, APACHE‐II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010; 105(2):435–41.
10 10. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002; 223:603–13.
11 11. Bakker OJ, van Brunschot S, vanSantvoort HC, Dutch Pancreatitis Study Group, et al. Early versus on‐demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med. 2014; 371(21):1983–93.
12 12. Lodewijkx PJ, Besselink MG, Witteman BJ, et al. Nutrition in acute pancreatitis: a critical review. Review Expert Rev Gastroenterol Hepatol. 2016; 10(5):571–80.
13 13. Barrie J1, Jamdar S1, Smith N, et al. Misuse of antibiotics in acute pancreatitis: Insights from the United Kingdom’s National Confidential Enquiry into patient outcome and death (NCEPOD) survey of acute pancreatitis. Pancreatology. 2018 Oct; 18(7):721–726.
14 14. da Costa DW, Bouwense SA, Schepers NJ, et al. Same‐admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015; 386(1000):1261–1268.
15 15. Steer ML, Wasman J, Freedman S. Chronic pancreatitis. N Engl J Med. 1995; 332:1482–90.
16 16. Machicado JD, Yadav D. Epidemiology of recurrent acute and chronic pancreatitis: similarities and differences. Dig Dis Sci. 2017 Jul; 62(7):1683–1691.
17 17. Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP. The different courses of early‐ and late‐onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology. 1994; 107(5):1481–7.
18 18. Sperti C, Moletta L. Staging chronic pancreatitis with exocrine function tests: Are we better? World J Gastroenterol. 2017 Oct 14; 23(38):6927–6930.
19 19. Holt PR. Intestinal malabsorption in the elderly. Dig Dis. 2007; 25:144–50.
20 20. Sanyal R, Stevens T, Novak E, Veniero JC. Secretin‐enhanced MRCP: review of technique and application with proposal for quantification of exocrine function. AJR Am J Roentgenol. 2012 Jan; 198(1):124–32.
21 21. Megibow AJ, Baker ME, Morgan DE. Management of incidental pancreatic cysts: a white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2017 Jul; 14(7):911–923.
22 22. Turaga KK, Kvois LK.