Pancreatic Cancer Clinical Presentation

Updated: Sep 11, 2018
  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Presentation

History

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. [14] 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. [43] 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.

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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.

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