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Pancreatic Cancer Clinical Presentation

  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
Updated: Jan 11, 2016


The early clinical diagnosis of pancreatic cancer is fraught with difficulty. Unfortunately, the initial symptoms of the disease are often quite nonspecific and subtle in onset. Consequently, these symptoms can be easily attributed to other processes unless the physician has a high index of suspicion for the possibility of underlying pancreatic carcinoma.

Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain.

Significant weight loss is a characteristic feature of pancreatic cancer.

Midepigastric pain is a common symptom of pancreatic cancer, with radiation of the pain to the midback or lower-back region sometimes occurring. Radiation of the pain to the back is worrisome, as it indicates retroperitoneal invasion of the splanchnic nerve plexus by the tumor.

Often, the pain is unrelenting in nature, with nighttime pain often being a predominant complaint. Some patients may note increased discomfort after eating. The pain may be worse when the patient is lying flat.

Weight loss may be related to cancer-associated anorexia and/or subclinical malabsorption from pancreatic exocrine insufficiency caused by pancreatic duct obstruction by the cancer. Patients with malabsorption usually complain about diarrhea and malodorous, greasy stools. Nausea and early satiety from gastric outlet obstruction and delayed gastric emptying from the tumor may also contribute to weight loss.

The onset of diabetes mellitus within the previous year is sometimes associated with pancreatic carcinoma. Even so, only about 1% of cases of new-onset diabetes mellitus in adults are related to occult pancreatic cancer.[37] Nevertheless, pancreatic cancer should be at least thought of in a patient older than 70 years with a new diagnosis of diabetes and without any other diabetic risk factors.

The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice. Patients with this sign may come to medical attention before their tumor grows large enough to cause abdominal pain. These patients usually notice a darkening of their urine and lightening of their stools before they or their families notice the change in skin pigmentation.

Physicians can usually recognize clinical jaundice when the total bilirubin reaches 2.5-3 mg%. Patients and their families do not usually notice clinical jaundice until the total bilirubin reaches 6-8 mg%. Urine darkening, stool changes, and pruritus are often noticed by patients before clinical jaundice.

Pruritus may accompany and often precedes clinical obstructive jaundice. Pruritus can often be the patient's most distressing symptom.

Depression is reported to be more common in patients with pancreatic cancer than in patients with other abdominal tumors. In some patients, depression may be the most prominent presenting symptom. This may in part be secondary to the high frequency of delayed diagnosis with this disease. In addition, although patients may not communicate it to their families, they are often aware that a serious illness of some kind is occurring in them.

A study by Turaga et al determined that male patients with pancreatic adenocarcinoma have a risk of suicide that is almost 11 times higher than the remainder of the population.[38] Patients who undergo surgery are more likely to commit suicide, specifically in the early postoperative period.

Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis also occur with higher frequency in patients with pancreatic cancer and may be the first presentation. Marantic endocarditis may develop in pancreatic cancer, occasionally being confused with subacute bacterial endocarditis.


Physical Examination

Pain is the most common presenting symptom in patients with pancreatic cancer. As previously mentioned, the pain typically takes the form of mild to moderate midepigastric tenderness. In some cases, radiation of the pain to the midback or lower-back region occurs. Such radiation is worrisome, as it indicates retroperitoneal invasion of the splanchnic nerve plexus by the tumor.

However, at the time of initial presentation, about one third of patients may not have pain, one third have moderate pain, and one third have severe pain. All patients experience pain at some point in their clinical course.

Patients with clinical jaundice may also have a palpable gallbladder (ie, Courvoisier sign) and may have skin excoriations from unrelenting pruritus.

Patients presenting with or developing advanced intra-abdominal disease may have ascites, a palpable abdominal mass, hepatomegaly from liver metastases, or splenomegaly from portal vein obstruction.

Subcutaneous metastases (referred to as a Sister Mary Joseph nodule or nodules) in the paraumbilical area signify advanced disease.

A metastatic mass in the rectal pouch may be palpable on rectal examination (Blumer's shelf).

A metastatic node may be palpable behind the medial end of the left clavicle (Virchow's node). However, other nodes in the cervical area may also be involved. Indeed, prior to the advent of computed tomography (CT) scanners to assess intra-abdominal disease, pancreatic cancer accounted for some 25% of adenocarcinomas of the cervical nodes, primary site unknown.

Contributor Information and Disclosures

Tomislav Dragovich, MD, PhD Chief, Section of Hematology and Oncology, Banner MD Anderson Cancer Center

Tomislav Dragovich, MD, PhD is a member of the following medical societies: American Association for Cancer Research, SWOG, American Society of Clinical Oncology

Disclosure: Nothing to disclose.


Richard A Erickson, MD, FACP, FACG Professor of Medicine, Division of Gastroenterology, Department of Internal Medicine, Texas A&M University Health Science Center; Director, Scott and White Clinic and Hospital

Richard A Erickson, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Mohsen Shabahang, MD, PhD, FACS Assistant Professor of Surgery, Division of Surgical Oncology, Director of Surgical Residency, Texas A&M Health Science Center, Scott and White Clinic

Mohsen Shabahang, MD, PhD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Surgical Oncology, Texas Medical Association, Western Surgical Association

Disclosure: Nothing to disclose.

Claire R Larson, MD Resident Physician, Department of General Surgery, Scott and White Hospital, Texas A&M Health Science Center College of Medicine

Claire R Larson, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Lodovico Balducci, MD Professor, Oncology Fellowship Director, Department of Internal Medicine, Division of Adult Oncology, H Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine

Lodovico Balducci, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American College of Physicians, American Geriatrics Society, American Society of Hematology, New York Academy of Sciences, American Society of Clinical Oncology, Southern Society for Clinical Investigation, International Society for Experimental Hematology, American Federation for Clinical Research, American Society of Breast Disease

Disclosure: Nothing to disclose.

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Pancreatic cancer. Gross section of an adenocarcinoma of the pancreas measuring 5 X 6 cm resected from the pancreatic body and tail. Although the tumor was considered to have been fully resected and had not spread to any nodes, the patient died of recurrent cancer within 1 year.
Pancreatic cancer. Hematoxylin and eosin stain of a pancreatic carcinoma. Note the intense desmoplastic response around the neoplastic cells. The large amount of fibrotic reaction in these tumors can make obtaining adequate tissue by fine-needle aspiration difficult.
Pancreatic cancer. T staging for pancreatic carcinoma. T1 and T2 stages are confined to the pancreatic parenchyma. T3 lesions invade local structures such as the duodenum, bile duct, and/or major peripancreatic veins, and T4 lesions invade surrounding organs (eg, stomach, colon, liver) or invade major arteries such as the superior mesenteric or celiac arteries.
Pancreatic cancer. Computerized tomographic scan showing a pancreatic adenocarcinoma of the pancreatic head. The gallbladder (gb) is distended because of biliary obstruction. The superior mesenteric artery (sma) is surrounded by tumor, making this an unresectable T4 lesion.
Pancreatic cancer. Abdominal CT scan of a small, vaguely seen, 2-cm pancreatic adenocarcinoma (mass) causing obstruction of both the common bile duct (cbd) and pancreatic duct (pd).
Pancreatic cancer. Endoscopic ultrasound of a 2.2-cm pancreatic adenocarcinoma of the head of the pancreas obstructing the common bile duct (CBD) but not invading the portal vein (PV) or superior mesenteric vein (SMV). Findings from endoscopic ultrasound–guided fine-needle aspiration revealed a moderately to poorly differentiated adenocarcinoma. Abdominal CT findings did not show this mass, and an attempt at endoscopic retrograde cholangiopancreatography at another institution was unsuccessful.
Algorithm for evaluation of a patient with suspected pancreatic cancer. CT scanning for definitive diagnosis and staging must be with thin-cut, multidetector, spiral CT scanning using dual-phase contrast imaging to allow for maximal information. This schema varies among institutions depending on local expertise, research interest, and therapeutic protocols for pancreatic carcinoma.
Pancreatic cancer. Tip of linear array echoendoscope (Pentax FG 36UX) with 22-gauge aspiration needle exiting from biopsy channel. Insert shows magnification of aspiration needle tip. Note that the needle exits from the biopsy channel such that it appears continuously in the view of the ultrasonic transducer on the tip of the echoendoscope.
Pancreatic cancer. Cytologic samples from fine-needle aspirations (rapid Papanicolaou stain) of pancreatic adenocarcinomas. (A) Well differentiated, (B) moderately differentiated, (C) moderate to poorly differentiated, (D) poorly differentiated tumor.
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