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pancreatic adenocarcinoma

Etiology: Risk factors: 1) cigarette smoking, relative risk 1.5 2) diet: high in meat & fat, low in vegetable & fruit 3) chronic pancreatitis, standardized incidence ratio 26.3 4) diabetes mellitus 5) obesity [3] 6) blood group other than type O [3] 5) chronic chemical exposure a) 2-naphthylamine b) benzidine c) gasoline derivatives 6) hereditary neoplastic syndrome (see genetics) 7) age > 60 years Epidemiology: 1) incidence in US is 10 in 100,000 2) male:female ratio 1.3 3) rare before 40 years of age; median age = 71 years [3] Pathology: 1) ductal adenocarcinoma - 90% of pancreatic cancers are ductal adenocarcinomas 2) majority of pancreatic adenocarcinomas are moderately to poorly differentiated [5] 2) extensive stromal reaction (desmoplasia) 3) hypovascular & hypoxic microenvironment 4) reprogramming of cellular metabolism 5) evasion of tumor immunity 6) local invasion into branches of the celiac artery or superior mesenteric artery 7) occlusion of the superior mesenteric vein 8) metastases typically to liver, peritoneum & occasionally to lung Genetics: - hereditary neoplastic syndromes [3] - hereditary pancreatitis - PRSS1, SPINK1 [3] - Peutz-Jehgers syndrome: STK11 - familial atypical mole & melanoma syndrome: p16 [3] - Lynch syndrome - MLH1, MSH2, MSH6 - Li-Fraumeni syndrome: p53 - ataxia telangiectasia: ATM [3] - activating mutations in KRAS (>90%) [3] - mutations in p16ink4A (80-95%) [5] - mutational inactivation of the CDKN2A, p53 (50-75%), & SMAD4 (55%) [3,5] - mutations in PRAD1, Ki-67 & BRCA2 [5] - also see pancreatic cancer Clinical manifestations: 1) jaundice*: majority of tumors occur in head of pancreas 2) weight loss* 3) pain a) abdominal or back b) worsened by lying down c) relieved by sitting of crouching 4) superficial thrombophlebitis (Trousseau's sign) 5% 5) pancreatitis may result from obstruction of pancreatic duct 6) glucose intolerance in 80% 7) depression 8) variceal hemorrhage (rare), splenic or portal vein 9) hepatomegaly with jaundice in advanced disease or metastases 10) portal hypertension may lead to ascites or peripheral edema * most common Laboratory: 1) serum chemistries may be abnormal, but are non-specific a) serum glucose b) serum amylase c) serum lipase d) serum alkaline phosphatase e) serum transaminases 2) mucinous glycoprotein levels are non-specific a) serum CA 19-9: - serum level > 800 ug/mL indicates a poor prognosis b) serum CA 50 3) serum C-reactive protein (CRP) - serum level > 200 mg/dL indicates a poor prognosis 4) genomic sequencing for patients that progress on standard therapy 5) multiplex IMMray PanCan-d assay has specificity of 98% & sensitivity of 87% in identifying pancreatic ductal adenocarcinoma among patients at increased genetic or familial risk [10] 6) urine biomarker panel (LYVE1, REG1B & TFF1) alone & in combination with plasma CA19-9 cab detect pancreatic adenocarcinoma up to 2 years prior to diagnosis [13] Special laboratory: - abdominal ultrasound is best initial diagnostic test - endoscopic ultrasound with fine-needle aspiration has similar accuracy as CT in assessing resectability in patients whose disease is unstaged & has a slight advantage over CT with respect to staging (lower chance is underestimating size of tumor) [4] Radiology: 1) abdominal CT for staging or equivocal ultrasound 2) MRI has no advantage over CT 3) ultrasound or CT-guided percutaneous needle biopsy 4) endoscopic ultrasound with transendoscopic fine-needle biopsy of lymph nodes is useful for staging 5) some surgeons use angiography to evaluate resectability Differential diagnosis: 1) chronic pancreatitis 2) cholecystitis 3) irritable bowel syndrome 4) retroperitoneal lymphoma or sarcoma 5) carcinoma of the duodenum 6) common bile duct stones & strictures 7) peptic ulcer disease 8) depression 9) ampullary carcinoma (better prognosis) 10) metastatic disease to the pancreas &/or retroperitoneum Staging: 1) high resolution multidetector CT a) 5-7 mm sections b) oral contrast 2) endoscopic ultrasound 3) stages: a) localized, resectable disease b) locally advanced disease c) metastatic disease * most patients initially diagnosed with stage I or II pancreatic ductal adenocarcinoma are upstaged following histopathology, potentially due to missed lymph nodes [14] Management: 1) surgery is the only curative treatment a) 15-20% are surgical candidates - tumor butting against the superior mesenteric artery prevents resection [5] b) pancreatoduodenectomy (Whipple's operation) is most popular procedure c) pre or postoperative radiotherapy with or without chemotherapy (5-fluorouracil or gemcitabine) d) neoadjuvant chemotherapy is the standard of care for borderline resectable & locally advanced pancreatic ductal adenocarcinoma [12] - adjuvant chemotherapy may prolong survival [12] e) combination chemotherapy - FOLFIRINOX - adjuvant FOLFIRINOX is the standard of care after pancreatic resection [9] - results in longer survival than gemcitabine [11] - gemcitabine + nab-paclitaxel - can lengthen survival from 3-6 months to 10-11 months [5] - erlotinib may add 2-weeks additional overall survival to gemcitabine therapy [5] f) perioperative chemotherapy does not improve overall 2-year survival in resected pancreatic adenocarcinoma [8] g) palliative surgery with unresectable tumor - cholecystojejunostomy for jaundice - gastrojejunostomy for duodenal obstruction - stents placed by ERCP - mean survival after palliative surgery is 5-6 months 2) unresectable or metastatic disease (stage 3 or 4) - combination adjuvant chemotherapy - FOLFIRINOX - gemcitabine + nab-paclitaxel - local radiation therapy may be an option [5] - conversion from unresectable to resectable does occur [5] - neoadjuvant FOLFIRINOX with individualized chemoradiotherapy for borderline resectable cancer [6] - FOLFIRINOX for 8 cycles followed by restaging - chemoradiotherapy (5 Gy x 5 with protons) with capecitabine if resolution of vascular involvement - chemoradiotherapy (50.4 Gy in 28 fractions) with fluorouracil or capecitabine if vascular involvement persists [6] - neoadjuvant FOLFIRINOX, losartan, followed by chemoradiotherapy for locally advanced pancreatic adenocarcinoma [7] 3) pain management - acetaminophen - non-steroidal anti-inflammatory drugs (NSAIDs) - morphine - codeine - percutaneous celiac plexus block 4) malabsorption with steatorrhea may be treated with pancreatic enzyme therapy with meals 5) prognosis: - 2 year survival 10% - 5 year survival 3% - 5-22% have resectable tumors, 15% survive 5 years - 5-year survival for node-negative disease is 25-30%; for node-positive disease ~10% [5] - life expectancy for unresectable tumors in 8-12 months [5] - same ref [5] says average survival is 4-6 months 6) follow-up - history & physical every 3-6 months for 2 years, then annually [5] - abdominal CT every 3-6 months for 2 years, then annually - serum CA 19.9 every 3-6 months for 2 years, then annually [5]

Interactions

disease interactions

Related

cancer antigen CA 19-9 (carbohydrate antigen 19-9) in serum cancer antigen CA 50 in serum pancreatic adenocarcinoma genotyping SMAD4/MADH4; mothers against decapentaplegic homolog 4; mothers against DPP homolog 4; MAD homolog 4; SMAD family member 4; SMAD 4; smad4; hSMAD4; deletion target in pancreatic carcinoma 4 (SMAD4, DPC4, MADH4)

General

adenocarcinoma exocrine pancreatic neoplasm

Database Correlations

OMIM 260350

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 382-83
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 18. American College of Physicians, Philadelphia 1998, 2009, 2018.
  3. Ryan DP, Hong TS, Bardeesy N Pancreatic Adenocarcinoma N Engl J Med 2014; 371:1039-1049 PMID: 25207767 http://www.nejm.org/doi/full/10.1056/NEJMra1404198 - Sumnners C What's new in KRAS mutation research? MD Anderson 2024. April 4 https://www.mdanderson.org/cancerwise/what-s-new-in-kras-mutation-research-.h00-159696756.html - Otto MA KRAS Inhibitors in Pancreatic Cancer: Hope on the Horizon? Medscape. Sept 6, 2024 https://www.medscape.com/viewarticle/kras-inhibitors-pancreatic-cancer-hope-horizon-2024a1000g6t
  4. Treadwell JR et al Imaging Rests for the Diagnosis and Staging of Pancreatic Adenocarcinoma. Effective Health Care Program. Comparative Effectiveness Review No. 141. Agency for Healthcare Research and Quality (AHRQ) http://www.effectivehealthcare.ahrq.gov/ehc/products/513/1972/cancer-pancreas-report-140929.pdf
  5. Kleynberg RL, Guralnik G Pancreatic Cancer: Difficult Diagnosis, Ominous Outlook. Medscape. March 24, 2016 http://reference.medscape.com/features/slideshow/pancreatic-cancer
  6. Murphy JE, Wo JY, Ryan DP et al Total Neoadjuvant Therapy With FOLFIRINOX Followed by Individualized Chemoradiotherapy for Borderline Resectable Pancreatic Adenocarcinoma. A Phase 2 Clinical Trial. JAMA Oncol. Published online May 3, 2018. PMID: 29800971 https://jamanetwork.com/journals/jamaoncology/fullarticle/2679565
  7. Murphy JE, Wo JY, Ryan DP et al Total Neoadjuvant Therapy With FOLFIRINOX in Combination With Losartan Followed by Chemoradiotherapy for Locally Advanced Pancreatic Cancer. A Phase 2 Clinical Trial. JAMA Oncol. Published online May 30, 2019 PMID: 31145418 https://jamanetwork.com/journals/jamaoncology/fullarticle/2734827
  8. Sohal DPS, Duong M, Ahmad SA et al Efficacy of Perioperative Chemotherapy for Resectable Pancreatic AdenocarcinomaA Phase 2 Randomized Clinical Trial. JAMA Oncol. Published online January 21, 2021 PMID: 33475684 https://jamanetwork.com/journals/jamaoncology/fullarticle/2775174
  9. Mavros MN, Moris D, Karanicolas PJ et al Clinical Trials of Systemic Chemotherapy for Resectable Pancreatic Cancer. A Review. JAMA Surg. Published online March 31, 2021. PMID: 33787841 https://jamanetwork.com/journals/jamasurgery/fullarticle/2777910
  10. Hamza Z Assay Shows Ability to Detect Pancreatic Cancer in People at High Risk. Serum-based test showed specificity of 98% and sensitivity of 85% for ID'ing early-stage PDAC. MedPage Today February 18, 2022 https://www.medpagetoday.com/gastroenterology/pancreaticdiseases/97283 - Brand RE, Persson J, Bratlie SO et al Detection of Early-Stage Pancreatic Ductal Adenocarcinoma from blood samples: Results of a multiplex biomarker signature validation study. Clin Transl Gastroenterol. 2022. February 14. PMID: 35166713 https://journals.lww.com/ctg/Abstract/9900/Detection_of_Early_Stage_Pancreatic_Ductal.26.aspx
  11. Conroy T, Castan F, Lopez A et al Five-Year Outcomes of FOLFIRINOX vs Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. A Randomized Clinical Trial. JAMA Oncol. 2022;8(11):1571-1578. PMID: 36048453 PMCID: PMC9437831 (available on 2023-09-01) https://jamanetwork.com/journals/jamaoncology/fullarticle/2795978
  12. Sugawara T, Franco SR, Sherman S et al Association of Adjuvant Chemotherapy in Patients With Resected Pancreatic Adenocarcinoma After Multiagent Neoadjuvant Chemotherapy. JAMA Oncol. Published online December 8, 2022 PMID: 36480190 https://jamanetwork.com/journals/jamaoncology/fullarticle/2799187
  13. Stewart J Urine Tests Could Be 'Enormous Step' in Diagnosing Cancer. Medscape. May 21, 2024 - Debernardi S, Blyuss O, Rycyk D et al Urine biomarkers enable pancreatic cancer detection up to 2 years before diagnosis. Int J Cancer. 2023 Feb 15;152(4):769-780. PMID: 36093581 PMCID: PMC9789171 Free PMC article.
  14. Perrotta G, Mohamed G, Larson BK et al Accuracy of Clinical Staging in Early-Stage Pancreatic Ductal Adenocarcinoma. JAMA. 2024 Sep 5:e2416332. PMID: 39235802 https://jamanetwork.com/journals/jama/article-abstract/2823280