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Overview

Practice Essentials

Pancreatic cancer is the tenth most common cancer in men and the eighth most common in women, but it is the fourth leading cause of cancer deaths, being responsible for about 7% of all cancer-related deaths.^[1]Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15-20% occur in the body of the pancreas, and 5-10% occur in the tail. See the image below.

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.

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Signs and symptoms

The initial symptoms of pancreatic cancer are often quite nonspecific and subtle in onset. Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain.

Patients with pancreatic cancer may present with the following signs and symptoms:

Significant weight loss: Characteristic feature of pancreatic cancer
Midepigastric pain: Common symptom of pancreatic cancer, sometimes with radiation of the pain to the midback or lower-back region
Often, unrelenting pain: Nighttime pain often a predominant complaint
Onset of diabetes mellitus within the previous year
Painless obstructive jaundice: Most characteristic sign of cancer of head of the pancreas
Pruritus: Often the patient's most distressing symptom
Depression
Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis: May be the first presentation
Palpable gallbladder (ie, Courvoisier sign)
Developing, advanced intra-abdominal disease: Presence of ascites, a palpable abdominal mass, hepatomegaly from liver metastases, or splenomegaly from portal vein obstruction
Advanced disease: Paraumbilical subcutaneous metastases (or Sister Mary Joseph nodule or nodules)
Possible presence of palpable metastatic mass in the rectal pouch (Blumer shelf)
Possible presence of palpable metastatic cervical nodes: Nodes may be palpable behind the medial end of the left clavicle (Virchow node) and other areas in the cervical region

See Presentation for more detail.

Diagnosis

Pancreatic cancer is notoriously difficult to diagnose in its early stages.^[2]

Testing

The laboratory findings in patients with pancreatic cancer are usually nonspecific. Patients with advanced pancreatic cancers and weight loss may have general laboratory evidence of malnutrition (eg, low serum albumin or cholesterol level).

Potentially useful tests in patients with suspected pancreatic cancer include the following:

CBC count
Hepatobiliary tests: Patients with obstructive jaundice show significant elevations in bilirubin (conjugated and total), ALP, GGT, and, to a lesser extent, AST and ALT
Serum amylase and/or lipase levels: Elevated in less than 50% of patients with resectable pancreatic cancers and in only 25% of patients with unresectable tumors
Tumor markers such as CA 19-9 antigen and CEA: 75-85% have elevated CA 19-9 levels; 40-45% have elevated CEA levels

Imaging studies

Imaging studies that aid in the diagnosis of pancreatic cancer include the following:

CT scanning
Transcutaneous ultrasonography
Endoscopic ultrasonography
Magnetic resonance imaging
Endoscopic retrograde cholangiopancreatography
Positron emission tomography scanning

See Workup for more detail.

See also Pancreatic Adenocarcinoma Imaging: What You Need to Know, a Critical Images slideshow, to help identify which imaging studies to use to identify and evaluate this disease.

Management

Surgery is the primary mode of treatment for pancreatic cancer. However, an important role exists for chemotherapy and/or radiation therapy.

Surgical options

Curative resection options include the following:

Pancreaticoduodenectomy (Whipple procedure), with/without sparing of the pylorus
Total pancreatectomy
Distal pancreatectomy

Chemotherapy

Modified FOLFIRINOX (5-fluorouracil [5-FU], oxaliplatin, irinotecan) is preferred for adjuvant therapy by the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN).^{[3, 4]}The NCCN also lists gemcitabine and capecitabine as a preferred regimen.^[4]Other antineoplastic agents and combinations of agents used in managing pancreatic carcinoma include the following:

Gemcitabine monotherapy - When toxicity is a concern^{[4, 5, 3]}
5-FU plus leucovorin^{[4, 3]}
Gemcitabine and albumin-bound paclitaxel^[4]
Paclitaxel protein bound 125 mg/m² plus gemcitabine 1000 mg/m² IV over 30-40 min on Days 1, 8, and 15 of each 28-day cycle^{[6, 7]}
Erlotinib plus gemcitabine
GTX (gemcitabine, docetaxel, capecitabine)
OFF (5-FU, leucovorin, oxaliplatin)
CapeOx (capecitabine, oxaliplatin)
Capecitabine monotherapy or capecitabine plus erlotinib: May provide second-line therapy benefit in patients with disease refractory to gemcitabine^[8]
Larotrectinib or entrectinib - Second-line therapy in patients with tumors harboring NTRK fusions^[5]

Neoadjuvant therapy

The use of chemotherapy and/or radiation therapy in the neoadjuvant setting has been a source of controversy, but increasing evidence supports its use in patients with resectable disease. Neoadjuvant regimen options include the following^[4]:

FOLFIRINOX/modified FOLFIRINOX, with or without subsequent chemoradiation
Gemcitabine + albumin-bound paclitaxel, with or without subsequent chemoradiation
Gemcitabine + cisplatin (2–6 cycles) followed by chemoradiation (only for known BRCA1/2 or PALB2 mutations)

Maintenance therapy

Olaparib is approved for maintenance treatment of adults with deleterious or suspected deleterious germline BRCA-mutated metastatic pancreatic adenocarcinoma whose disease has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen.

Palliative Therapy

Palliative therapy may be administered for the following conditions associated with pancreatic cancer:

Pain: Pain relief is crucial for patients not undergoing resection for pancreatic cancer; narcotic analgesics should be used early and in adequate dosages
Jaundice: Obstructive jaundice warrants palliation if the patient has pruritus or right upper quadrant pain or has developed cholangitis
Duodenal obstruction secondary to pancreatic carcinoma: Can be palliated operatively with a gastrojejunostomy or an endoscopic procedure

See Treatment and Medication for more detail.

For patient education information, see Pancreatic Cancer.

Background

Although pancreatic cancer accounts for only about 3% of all cancers in the United States, it is the fourth leading cause of cancer deaths in both men and women, being responsible for 7% of all cancer-related deaths. The average lifetime risk of developing pancreatic cancer is about 1 in 64.^[9](See Epidemiology.)

Pancreatic cancer is notoriously difficult to diagnose in its early stages. At the time of diagnosis, 52% of all patients have distant disease and 26% have regional spread. The relative 1-year survival rate for pancreatic cancer is only 28%, and the overall 5-year survival is 7%.^[10](See Prognosis and Workup.)

Types of pancreatic cancer

Of all pancreatic cancers, 80% are adenocarcinomas of the ductal epithelium. Only 2% of tumors of the exocrine pancreas are benign. (See Etiology and Histologic Findings.)

Less common histologic appearances of exocrine pancreatic cancers include giant cell carcinoma, adenosquamous carcinoma, microglandular adenocarcinoma, mucinous carcinoma, cystadenocarcinoma, papillary cystic carcinoma, acinar cystadenocarcinoma, and acinar cell cystadenocarcinoma. Very rarely, primary connective tissue cancers of the pancreas can occur. The most common of these is primary pancreatic lymphoma.

An adenocarcinoma of the pancreas is seen below. (See Histologic Findings.)

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Pathophysiology

Typically, pancreatic cancer first metastasizes to regional lymph nodes, then to the liver and, less commonly, to the lungs. It can also directly invade surrounding visceral organs such as the duodenum, stomach, and colon, or it can metastasize to any surface in the abdominal cavity via peritoneal spread. Ascites may result, and this has an ominous prognosis. Pancreatic cancer may spread to the skin as painful nodular metastases. Metastasis to bone is uncommon.

Pancreatic cancer rarely spreads to the brain, but it can produce meningeal carcinomatosis.

Etiology

Pancreatic cancers can arise from the exocrine and endocrine portions of the pancreas, but 93% of them develop from the exocrine portion, including the ductal epithelium, acinar cells, connective tissue, and lymphatic tissue. Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15-20% occur in the body of the pancreas, and 5-10% occur in the tail.

Tobacco smoking is the most common recognized risk factors for pancreatic cancer. Others include obesity, high alcohol consumption, history of pancreatitis and diabetes, family history of pancreatic cancer, and possibly selected dietary factors.^[11]Only 5-10% are hereditary in nature.^[12]

Because excess risk for pancreatic cancer is greater in patients recently diagnosed with diabetes mellitus, it has been suggested that diabetes may be at least in part a consequence or an early manifestation of pancreatic cancer. However, the International Pancreatic Cancer Case-Control Consortium reported that a 30% excess risk for pancreatic cancer persists for more than 2 decades after diabetes diagnosis, which supports the hypothesis that diabetes has a causal role in pancreatic cancer.^[13]

Less than 5% of all pancreatic cancers are related to underlying chronic pancreatitis. Alcohol consumption does not appear to be an independent risk factor for pancreatic cancer unless it is associated with chronic pancreatitis.

The risk factors for pancreatic cancer are discussed in more detail below.

Smoking

Smoking is the most common environmental risk factor for pancreatic carcinoma. Estimates indicate that smoking accounts for up to 30% of cases of pancreatic cancer.

People who smoke have at least a 2-fold greater risk for pancreatic cancer than do nonsmokers. Current smokers with over a 40 pack-year history of smoking may have up to a 5-fold risk greater risk for the disease. Smokeless tobacco also increases the risk of pancreatic cancer.

It takes 5-10 years of discontinued smoking to reduce the increased risk of smoking to approximately that of nonsmokers.

Obesity and dietary factors

In a number of studies, obesity, especially central, has been associated with a higher incidence of pancreatic cancer. For example, Li et al found that being overweight or obese during early adulthood was associated with a greater risk of pancreatic cancer and a younger age of disease onset, while obesity at an older age was associated with lower overall survival.^[14]Several other studies have supported a link between early obesity and the risk of pancreatic cancer.^{[15, 16]}

The incidence of pancreatic cancer is lower in persons with a diet rich in fresh fruits and vegetables. Fruits and vegetables rich in folate and lycopenes (such as tomatoes) may be especially good at reducing the risk of pancreatic cancer.^{[17, 18]}

Consumption of red meat, especially of the processed kinds, is associated with a higher risk of pancreatic cancer. Poultry and dairy product consumption does not increase the risk of this disease.^[19]

Despite early reports to the contrary, coffee consumption is not associated with an increased risk of pancreatic cancer.^[20]

Diabetes mellitus

Numerous studies have examined the relative risk of pancreatic cancer in persons with diabetes mellitus. A systematic review of 30 studies concluded that patients with diabetes mellitus of at least 5-years' duration have a 2-fold increased risk of developing pancreatic carcinoma. Pancreatic cancer may follow 18-36 months after a diagnosis of diabetes mellitus in elderly patients with no family history of diabetes mellitus.

The National Comprehensive Cancer Network (NCCN) acknowledges long-standing diabetes mellitus as a risk factor for pancreatic cancer. The NCCN also notes an association between sudden onset of type II diabetes mellitus in an adult older than 50 years and a new diagnosis of pancreatic cancer, although in those cases the diabetes is thought to be caused by the cancer.^[4]

Chronic pancreatitis

Long-standing, chronic pancreatitis is a substantial risk factor for the development of pancreatic cancer. A multicenter study of more than 2000 patients with chronic pancreatitis showed a 26-fold increase in the risk of developing pancreatic cancer. This risk increased linearly with time, with 4% of patients who had chronic pancreatitis for 20 years' duration developing pancreatic cancer.^[21]

The risk of pancreatic cancer is even higher in patients with hereditary pancreatitis. The mean age of development of pancreatic cancer in these patients is approximately 57 years. The relative risk of pancreatic cancer in hereditary pancreatitis is increased more than 50-fold, and the cumulative risk rate of pancreatic cancer by age 70 years is 40%.

This cumulative risk increases to 75% in persons whose family has a paternal inheritance pattern.^[22]

Chronic pancreatitis from alcohol consumption is also associated a much higher incidence and an earlier age of onset of pancreatic carcinoma.^[23]

Genetic factors

Approximately 5-10% of patients with pancreatic carcinoma have some genetic predisposition to developing the disease.^[24]

The molecular genetics of pancreatic adenocarcinoma have been well studied.^{[25, 26, 27]}Of these tumors, 80-95% have mutations in the KRAS2 gene; 85-98% have mutations, deletions, or hypermethylation in the CDKN2 gene; 50% have mutations in p53; and about 55% have homozygous deletions or mutations in Smad4. Some of these mutations can also be found in high-risk precursors of pancreatic cancer. For example, in chronic pancreatitis, 30% of patients have detectable mutations in p16 and 10% have K-ras mutations.

Families with BRCA-2 mutations, which are associated with a high risk of breast cancer, also have an excess of pancreatic cancer.^[28]

Assaying pancreatic juice for the genetic mutations associated with pancreatic adenocarcinoma is invasive, but it may be useful for the early diagnosis of the disease.^[29]However, this approach is problematic, because genetic mutations in the pancreatic juice may be found in patients with inflammatory pancreatic disease.

Certain precursor lesions have been associated with pancreatic tumors arising from the ductal epithelium of the pancreas. The main morphologic form associated with ductal adenocarcinoma of the pancreas is pancreatic intraepithelial neoplasia (PIN). These lesions arise from specific genetic mutations and cellular alterations that contribute to the development of invasive ductal adenocarcinoma.^[30]

The initial alterations appear to be related to KRAS2 gene mutations and telomere shortening. Thereafter, p16/CDKN2A is inactivated. Finally, the inactivation of TP53 and MAD4/DPC4 occur. These mutations have been correlated with increasing development of dysplasia and thus with the development of ductal carcinoma of the exocrine pancreas.

Based on more recent data from sequencing of human tumors, pancreatic cancer is a genetically complex and heterogeneous disease.^[31]This is confounded by considerable variability in terms of the genetic malformations and pathways involved between individual tumors. In addition, the long time from early to clinically manifested disease (21.2 y on average) allows for an accumulation of complex genetic changes, which probably explains the fact that it is often resistant to chemotherapy and radiation therapy.^{[32, 33]}

The inherited disorders that increase the risk of pancreatic cancer include hereditary pancreatitis, multiple endocrine neoplasia (MEN), hereditary nonpolyposis rectal cancer (HNPCC), familial adenomatous polyposis (FAP) and Gardner syndrome, familial atypical multiple mole melanoma (FAMMM) syndrome, von Hippel-Lindau syndrome (VHL), and germline mutations in the BRCA1 and BRCA2 genes.

Hereditary pancreatitis has been associated with a 40% cumulative risk of developing pancreatic cancer at 40%.^[22]MEN-1 and VHL are other genetic syndromes associated with pancreatic endocrine tumor development.

Patients with MEN-1 develop symptomatic pancreatic endocrine tumors about 50% of the time, and these pancreatic tumors are noted to be the leading cause of disease-specific mortality.^[34]Von Hippel-Lindau syndrome has been associated with malignancy in 17% of masses found in the pancreas in people with this syndrome.^[35]

Syndromes associated with an increased risk of the development of colon cancer, such as HNPCC and FAP (and Gardner syndrome), have also shown an increased correlation with existence of pancreatic cancer, but the statistics have not been impressive.

In a cohort study of 1391 patients with FAP, only 4 developed pancreatic adenocarcinoma. No statistics are available to show the incidence of pancreatic cancer in patients with HNPCC.^[36]

FAMMM has been shown to increase relative risk of developing pancreatic cancer by 13- to 22-fold and the incidence in sporadic cases to be 98%.^[37]

The above disorders have specific genetic abnormalities associated with the noted increased risk of pancreatic cancer. Pancreatic cancer in hereditary pancreatitis is associated with a mutation in the PRSS1 gene. Pancreatic cancer appearing in FAP and HNPCC has been associated with a mutation in the APC gene and MSH2 and MLH1 genes respectively. FAMMM and pancreatic cancer has been associated with a mutation in CDKN2A. Endocrine tumors of the pancreas associated with VHL are thought to develop by way of the inactivation of the VHL tumor suppressor gene.^[24]

Germline mutations in BRCA1 and BRCA2 have been shown to moderately increase the risk of developing pancreatic cancer by 2.3- to 3.6-fold, but BRCA2 has been associated more commonly with pancreatic cancer, at an incidence of 7%.^[24]

Race-related factors

Black males in the United States have the highest incidence rate of pancreatic cancer.^[38](See Epidemiology, below.) The reasons for the higher incidence of pancreatic cancer in African Americans are unclear. Certainly, differences in risk factors for pancreatic cancer, such as dietary habits, obesity, and the frequency of cigarette smoking, are recognized among different population groups and may contribute to the higher incidence of this disease among blacks.

However, Arnold et al found that excess pancreatic cancer in blacks cannot be attributed to currently known risk factors, suggesting that as-yet undetermined factors play a role in the disease process.^[39]One possibility is a difference in the underlying frequency of predisposing genetic mutations for pancreatic cancer.

Incidence in the United States

The American Cancer Society estimates that in the United States in 2021, about 60,430 new cases of pancreatic cancer (31,950 in men and 28,480 in women) will be diagnosed. The overall incidence rate of pancreatic cancer has increased about 1% per year since 2000.^[10]

International incidence

Worldwide, pancreatic cancer ranks 11th in incidence but 7th as a cause of cancer death.^[40]The age-standardized rate (ASR) incidence ranges widely, from 7.7 per 100,000 population in Europe to 2.2 per 100,000 population in Africa. Among individual countries, ASRs range from 0.81 per 100,000 in males in India to 15.3 per 100,000 in males in Latvia and the Republic of Moldova.^[40]

Race predilection

From 2011 to 2015, the highest incidence rate of pancreatic cancer in the United States was 16.9 cases per 100,000 persons per year, in black men. The incidences in men in other racial/ethnic groups were as follows^[9]:

Non-Hispanic: 14.7
White: 14.4
Hispanic: 12.0
American Indian/Alaska Native: 11.3
Asian/Pacific Islander: 11.0

The incidences in US women during that period were as follows^[9]:

Black: 14.3
Non-Hispanic: 11.3
White: 11.1
Hispanic: 10.5
Asian/Pacific Islander: 9.2
American Indian/Alaska Native: 7.8

Age predilection

In the absence of predisposing conditions, such as familial pancreatic cancer and chronic pancreatitis, pancreatic cancer is unusual in persons younger than 45 years. After age 50 years, the frequency of pancreatic cancer increases linearly.

The median age at diagnosis is 69 years in whites and 65 years in blacks; some single-institution data reported from large cancer centers suggest that the median age at diagnosis in both sexes has fallen to 63 years of age.

Mortality

Although pancreatic cancer constitutes only about 3% of all cancers in the United States, it is the fourth leading cause of cancer deaths in both men and women, being responsible for 8% of all cancer-related deaths.The American Cancer Society estimates that in the United States in 2020, about 47,050 people (24,640 men and 22,410 women) will die of pancreatic cancer. During 2008 to 2017, the death rate for pancreatic cancer increased slightly (by 0.4% per year) in whites and decreased slightly (by 0.5% per year) in blacks.^[10]

Prognosis

Pancreatic carcinoma is unfortunately usually a fatal disease. The collective median survival time for all patients is 4-6 months.

The relative 1-year survival rate for patients with pancreatic cancer is only 28%, and the overall 5-year survival rate is 9%, having increased from 3% between 1975 and 1977.^[9]By stage, 5-year relative survival is 34.3% for localized disease, 11.5% for regional disease, and 2.7% for distant disease.^[9]At the time of diagnosis, 52% of patients have distant disease.^[10](However, patients with neuroendocrine and cystic neoplasms of the pancreas, such as mucinous cystadenocarcinomas or intraductal papillary mucinous neoplasms [IPMN], have much better survival rates than do patients with pancreatic adenocarcinoma).

A 5-year survival in pancreatic cancer is no guarantee of cure; patients who survive for 5 years after successful surgery may still die of recurrent disease years after the 5-year survival point. The occasional patient with metastatic disease or locally advanced disease who survives beyond 2-3 years may die of complications of local spread, such as bleeding esophageal varices.

In patients able to undergo a successful curative resection (about 20% of patients), median survival time ranges from 12-19 months, and the 5-year survival rate is 15-20%. The best predictors of long-term survival after surgery are a tumor diameter of less than 3 cm, no nodal involvement, negative resection margins, and diploid tumor deoxyribonucleic acid (DNA) content.

The median survival for patients who undergo successful resection (only 20% of patients) is approximately 12-19 months, with a 5-year survival rate of 15-20%.

Tingle et al reported that in patients with unresectable pancreatic ductal adenocarcinoma, the combination of the neutrophil-albumin ratio (NAR) and the Ca19-9 level allows stratification into three groups with significantly different overall survival, as follows^[41]:

NAR ≤ 0.13 and Ca19-9 ≤ 770 U/mL - Median survival 20.5 months
NAR > 0.13 or Ca19-9 >770 - Median survival 9.7 months
NAR > 0.13 and Ca19-9 > 770 - Median survival 4.1 months

Patient Education

Smoking is the most significant reversible risk factor for pancreatic cancer.

Alcohol consumption does not increase the risk of pancreatic cancer unless it leads to chronic pancreatitis. A multicenter study of more than 2000 patients with chronic pancreatitis showed a 26-fold increase in the risk of developing pancreatic cancer.^[21]

For patient education information, see the Pancreatic Cancer Health Center.

Clinical Presentation

Cancer Facts & Figures 2021. American Cancer Society. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf. Accessed: October 6, 2021.
PDQ Adult Treatment Editorial Board. Pancreatic Cancer Treatment (PDQ®): Health Professional Version. February 3, 2021. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Khorana AA, McKernin SE, Berlin J, Hong TS, Maitra A, Moravek C, et al. Potentially Curable Pancreatic Adenocarcinoma: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2019 Aug 10. 37 (23):2082-2088. [QxMD MEDLINE Link]. [Full Text].
[Guideline] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. NCCN. Available at http://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Version 2.2021 — February 25, 2021; Accessed: October 6, 2021.
[Guideline] Sohal DPS, Kennedy EB, Cinar P, Conroy T, Copur MS, Crane CH, et al. Metastatic Pancreatic Cancer: ASCO Guideline Update. J Clin Oncol. 2020 Aug 5. JCO2001364. [QxMD MEDLINE Link]. [Full Text].
Von Hoff DD, Arena FP, Chiorean EG, Infante JR, Moore MJ, Seay TE, et al. Randomized phase III study of weekly nab-paclitaxel plus gemcitabine versus gemcitabine alone in patients with metastatic adenocarcinoma of the pancreas (MPACT). J Clin Oncol 30: 2012 (suppl 34; abstr LBA148), Presented January 25, 2013 at the 2013 Gastrointestinal Cancers Symposium, San Francisco, CA.
Mulcahy N. FDA Approves Nab-Paclitaxel for Pancreatic Cancer. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/810564. September 06, 2013; Accessed: September 09, 2018.
Kulke MH, Blaszkowsky LS, Ryan DP, Clark JW, Meyerhardt JA, Zhu AX, et al. Capecitabine plus erlotinib in gemcitabine-refractory advanced pancreatic cancer. J Clin Oncol. 2007 Oct 20. 25(30):4787-92. [QxMD MEDLINE Link].
Cancer Stat Facts: Pancreatic Cancer. National Cancer Institute. Available at https://seer.cancer.gov/statfacts/html/pancreas.html. Accessed: October 6, 2021.
Key Statistics for Pancreatic Cancer. American Cancer Society. Available at https://www.cancer.org/cancer/pancreatic-cancer/about/key-statistics.html. January 21, 2021; Accessed: October 6, 2021.
Maisonneuve P, Lowenfels AB. Epidemiology of pancreatic cancer: an update. Dig Dis. 2010. 28 (4-5):645-56. [QxMD MEDLINE Link].
Raimondi S, Maisonneuve P, Lowenfels AB. Epidemiology of pancreatic cancer: an overview. Nat Rev Gastroenterol Hepatol. 2009 Dec. 6(12):699-708. [QxMD MEDLINE Link].
Bosetti C, Rosato V, Li D, Silverman D, Petersen GM, et al. Diabetes, antidiabetic medications, and pancreatic cancer risk: an analysis from the International Pancreatic Cancer Case-Control Consortium. Ann Oncol. 2014 Oct. 25 (10):2065-72. [QxMD MEDLINE Link]. [Full Text].
Li D, Morris JS, Liu J, Hassan MM, Day RS, Bondy ML, et al. Body mass index and risk, age of onset, and survival in patients with pancreatic cancer. JAMA. 2009 Jun 24. 301(24):2553-62. [QxMD MEDLINE Link]. [Full Text].
Genkinger JM, Spiegelman D, Anderson KE, et al. A pooled analysis of 14 cohort studies of anthropometric factors and pancreatic cancer risk. Int J Cancer. 2011 Oct 1. 129(7):1708-17. [QxMD MEDLINE Link]. [Full Text].
Urayama KY, Holcatova I, Janout V, et al. Body mass index and body size in early adulthood and risk of pancreatic cancer in a central European multicenter case-control study. Int J Cancer. 2011 Dec 15. 129(12):2875-84. [QxMD MEDLINE Link]. [Full Text].
Nkondjock A, Ghadirian P, Johnson KC, Krewski D. Dietary intake of lycopene is associated with reduced pancreatic cancer risk. J Nutr. 2005 Mar. 135(3):592-7. [QxMD MEDLINE Link].
Risch HA. Etiology of pancreatic cancer, with a hypothesis concerning the role of N-nitroso compounds and excess gastric acidity. J Natl Cancer Inst. 2003 Jul 2. 95(13):948-60. [QxMD MEDLINE Link].
Nöthlings U, Wilkens LR, Murphy SP, Hankin JH, Henderson BE, Kolonel LN. Meat and fat intake as risk factors for pancreatic cancer: the multiethnic cohort study. J Natl Cancer Inst. 2005 Oct 5. 97(19):1458-65. [QxMD MEDLINE Link].
Lin Y, Tamakoshi A, Kawamura T, et al. Risk of pancreatic cancer in relation to alcohol drinking, coffee consumption and medical history: findings from the Japan collaborative cohort study for evaluation of cancer risk. Int J Cancer. 2002 Jun 10. 99(5):742-6. [QxMD MEDLINE Link].
Lowenfels AB, Maisonneuve P, Cavallini G, Ammann RW, Lankisch PG, Andersen JR, et al. Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med. 1993 May 20. 328(20):1433-7. [QxMD MEDLINE Link].
Cowgill SM, Muscarella P. The genetics of pancreatic cancer. Am J Surg. 2003 Sep. 186(3):279-86. [QxMD MEDLINE Link].
Whitcomb DC. Genetics and alcohol: a lethal combination in pancreatic disease?. Alcohol Clin Exp Res. 2011 May. 35(5):838-42. [QxMD MEDLINE Link].
Mintziras I, Bartsch DK. Progress report: familial pancreatic cancer. Fam Cancer. 2019 Feb 22. 102(11):2564-9. [QxMD MEDLINE Link].
Soto JL, Barbera VM, Saceda M, Carrato A. Molecular biology of exocrine pancreatic cancer. Clin Transl Oncol. May 2006. 8:306-12. [QxMD MEDLINE Link].
Hahn SA, Kern SE. Molecular genetics of exocrine pancreatic neoplasms. Surg Clin North Am. 1995 Oct. 75(5):857-69. [QxMD MEDLINE Link].
Shi C, Daniels JA, Hruban RH. Molecular characterization of pancreatic neoplasms. Adv Anat Pathol. 2008 Jul. 15(4):185-95. [QxMD MEDLINE Link].
Goggins M, Schutte M, Lu J, et al. Germline BRCA2 gene mutations in patients with apparently sporadic pancreatic carcinomas. Cancer Res. 1996 Dec 1. 56(23):5360-4. [QxMD MEDLINE Link].
Yan L, McFaul C, Howes N, Leslie J, Lancaster G, Wong T, et al. Molecular analysis to detect pancreatic ductal adenocarcinoma in high-risk groups. Gastroenterology. June 2005. 128:2124-30. [QxMD MEDLINE Link].
Kojima K, Vickers SM, Adsay NV, et al. Inactivation of Smad4 accelerates Kras(G12D)-mediated pancreatic neoplasia. Cancer Res. 2007 Sep 1. 67(17):8121-30. [QxMD MEDLINE Link].
Jones S, Zhang X, Parsons DW, et al. Core signaling pathways in human pancreatic cancers revealed by global genomic analyses. Science. 2008 Sep 26. 321(5897):1801-6. [QxMD MEDLINE Link]. [Full Text].
Yachida S, Jones S, Bozic I, et al. Distant metastasis occurs late during the genetic evolution of pancreatic cancer. Nature. 2010 Oct 28. 467(7319):1114-7. [QxMD MEDLINE Link].
Campbell PJ, Yachida S, Mudie LJ, et al. The patterns and dynamics of genomic instability in metastatic pancreatic cancer. Nature. 2010 Oct 28. 467(7319):1109-13. [QxMD MEDLINE Link].
Kouvaraki MA, Shapiro SE, Cote GJ, Lee JE, Yao JC, Waguespack SG, et al. Management of pancreatic endocrine tumors in multiple endocrine neoplasia type 1. World J Surg. 2006 May. 30(5):643-53. [QxMD MEDLINE Link].
Blansfield JA, Choyke L, Morita SY, Choyke PL, Pingpank JF, Alexander HR, et al. Clinical, genetic and radiographic analysis of 108 patients with von Hippel-Lindau disease (VHL) manifested by pancreatic neuroendocrine neoplasms (PNETs). Surgery. 2007 Dec. 142(6):814-8; discussion 818.e1-2. [QxMD MEDLINE Link].
Groen EJ, Roos A, Muntinghe FL, Enting RH, de Vries J, Kleibeuker JH, et al. Extra-intestinal manifestations of familial adenomatous polyposis. Ann Surg Oncol. 2008 Sep. 15(9):2439-50. [QxMD MEDLINE Link].
Lynch HT, Fusaro RM, Lynch JF, Brand R. Pancreatic cancer and the FAMMM syndrome. Fam Cancer. 2008. 7(1):103-12. [QxMD MEDLINE Link].
American Cancer Society. Cancer facts and figures for African Americans 2019-2021. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf. Accessed: October 6, 2021.
Arnold LD, Patel AV, Yan Y, Jacobs EJ, Thun MJ, Calle EE, et al. Are racial disparities in pancreatic cancer explained by smoking and overweight/obesity?. Cancer Epidemiol Biomarkers Prev. 2009 Sep. 18(9):2397-405. [QxMD MEDLINE Link].
Rawla P, Sunkara T, Gaduputi V. Epidemiology of Pancreatic Cancer: Global Trends, Etiology and Risk Factors. World J Oncol. 2019 Feb. 10 (1):10-27. [QxMD MEDLINE Link]. [Full Text].
Tingle SJ, Severs GR, Goodfellow M, Moir JA, White SA. NARCA: A novel prognostic scoring system using neutrophil-albumin ratio and Ca19-9 to predict overall survival in palliative pancreatic cancer. J Surg Oncol. 2018 Sep 9. [QxMD MEDLINE Link].
Turaga KK, Malafa MP, Jacobsen PB, Schell MJ, Sarr MG. Suicide in patients with pancreatic cancer. Cancer. 2011 Feb 1. 117(3):642-7. [QxMD MEDLINE Link].
[Guideline] Locker GY, Hamilton S, Harris J, Jessup JM, Kemeny N, Macdonald JS, et al. ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol. 2006 Nov 20. 24(33):5313-27. [QxMD MEDLINE Link].
Fujioka S, Misawa T, Okamoto T, Gocho T, Futagawa Y, Ishida Y, et al. Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels for the evaluation of curability and resectability in patients with pancreatic adenocarcinoma. J Hepatobiliary Pancreat Surg. 2007. 14(6):539-44. [QxMD MEDLINE Link].
Kang CM, Kim JY, Choi GH, Kim KS, Choi JS, Lee WJ. The use of adjusted preoperative CA 19-9 to predict the recurrence of resectable pancreatic cancer. J Surg Res. 2007 Jun 1. 140(1):31-5. [QxMD MEDLINE Link].
Horton KM, Fishman EK. Multidetector CT angiography of pancreatic carcinoma: part I, evaluation of arterial involvement. AJR Am J Roentgenol. 2002 Apr. 178(4):827-31. [QxMD MEDLINE Link].
Horton KM, Fishman EK. Adenocarcinoma of the pancreas: CT imaging. Radiol Clin North Am. 2002 Dec. 40(6):1263-72. [QxMD MEDLINE Link].
Kauhanen SP, Komar G, Seppänen MP, Dean KI, Minn HR, Kajander SA, et al. A prospective diagnostic accuracy study of 18F-fluorodeoxyglucose positron emission tomography/computed tomography, multidetector row computed tomography, and magnetic resonance imaging in primary diagnosis and staging of pancreatic cancer. Ann Surg. 2009 Dec. 250(6):957-63. [QxMD MEDLINE Link].
Farma JM, Santillan AA, Melis M, Walters J, Belinc D, Chen DT, et al. PET/CT fusion scan enhances CT staging in patients with pancreatic neoplasms. Ann Surg Oncol. 2008 Sep. 15(9):2465-71. [QxMD MEDLINE Link].
Itani KM, Taylor TV, Green LK. Needle biopsy for suspicious lesions of the head of the pancreas: pitfalls and implications for therapy. J Gastrointest Surg. 1997 Jul-Aug. 1(4):337-41. [QxMD MEDLINE Link].
Turner BG, Cizginer S, Agarwal D, Yang J, Pitman MB, Brugge WR. Diagnosis of pancreatic neoplasia with EUS and FNA: a report of accuracy. Gastrointest Endosc. 2010 Jan. 71(1):91-8. [QxMD MEDLINE Link].
Micames C, Jowell PS, White R, Paulson E, Nelson R, Morse M, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA. Gastrointest Endosc. 2003 Nov. 58(5):690-5. [QxMD MEDLINE Link].
Louden K. New risk factors proposed for pancreatic cancer. Medscape Medical News. September 26, 2013. [Full Text].
[Guideline] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Neuroendocrine Tumors. Available at http://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf. Version 3.2021 — August 13, 2021; Accessed: October 6, 2021.
Tempero MA. NCCN Guidelines Updates: Pancreatic Cancer. J Natl Compr Canc Netw. 2019 May 1. 17 (5.5):603-605. [QxMD MEDLINE Link]. [Full Text].
Le DT, Durham JN, Smith KN, et al. Mismatch repair deficiency predicts response of solid tumors to PD-1 blockade. Science. 2017 Jul 28. 357 (6349):409-413. [QxMD MEDLINE Link]. [Full Text].
Katz MH, Hwang R, Fleming JB, Evans DB. Tumor-node-metastasis staging of pancreatic adenocarcinoma. CA Cancer J Clin. 2008 Mar-Apr. 58(2):111-25. [QxMD MEDLINE Link].
Callery MP, Strasberg SM, Doherty GM, Soper NJ, Norton JA. Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy. J Am Coll Surg. 1997 Jul. 185(1):33-9. [QxMD MEDLINE Link].
Vollmer CM, Drebin JA, Middleton WD, Teefey SA, Linehan DC, Soper NJ. Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies. Ann Surg. 2002 Jan. 235(1):1-7. [QxMD MEDLINE Link].
Jarnagin WR, Bodniewicz J, Dougherty E, Conlon K, Blumgart LH, Fong Y. A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies. J Gastrointest Surg. 2000 Jan-Feb. 4(1):34-43. [QxMD MEDLINE Link].
Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T. Vascular resection and reconstruction for pancreatic malignancy: a single center survival study. J Gastrointest Surg. 2007 Sep. 11(9):1168-74. [QxMD MEDLINE Link].
[Guideline] Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, et al. Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2015 Sep. 26 Suppl 5:v56-v68. [QxMD MEDLINE Link]. [Full Text].
Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, et al. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. Br J Surg. 2015 Feb. 102 (3):182-93. [QxMD MEDLINE Link].
Dreyer SB, Upstill-Goddard R, Paulus-Hock V, et al. Targeting DNA Damage Response and Replication Stress in Pancreatic Cancer. Gastroenterology. 2020 Oct 8. [QxMD MEDLINE Link].
Pisters PW, Abbruzzese JL, Janjan NA, Cleary KR, Charnsangavej C, Goswitz MS. Rapid-fractionation preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for resectable pancreatic adenocarcinoma. J Clin Oncol. 1998 Dec. 16(12):3843-50. [QxMD MEDLINE Link].
Pisters PW, Wolff RA, Janjan NA, Cleary KR, Charnsangavej C, Crane CN. Preoperative paclitaxel and concurrent rapid-fractionation radiation for resectable pancreatic adenocarcinoma: toxicities, histologic response rates, and event-free outcome. J Clin Oncol. 2002 May 15. 20(10):2537-44. [QxMD MEDLINE Link].
Dhir M, Zenati MS, Hamad A, Singhi AD, Bahary N, Hogg ME, et al. FOLFIRINOX Versus Gemcitabine/Nab-Paclitaxel for Neoadjuvant Treatment of Resectable and Borderline Resectable Pancreatic Head Adenocarcinoma. Ann Surg Oncol. 2018 Jul. 25 (7):1896-1903. [QxMD MEDLINE Link].
Kadera BE, Sunjaya DB, Isacoff WH, Li L, Hines OJ, Tomlinson JS, et al. Locally Advanced Pancreatic Cancer: Association Between Prolonged Preoperative Treatment and Lymph-Node Negativity and Overall Survival. JAMA Surg. 2013 Dec 4. [QxMD MEDLINE Link].
Boggs W. Preop Chemo for Locally Advanced Pancreatic Cancer Associated With 'Excellent' Survival. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/817801. Accessed: December 22, 2013.
Loehrer PJ Sr, Feng Y, Cardenes H, et al. Gemcitabine alone versus gemcitabine plus radiotherapy in patients with locally advanced pancreatic cancer: an eastern cooperative oncology group trial. J Clin Oncol. 2011 Nov 1. 29(31):4105-12. [QxMD MEDLINE Link].
McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg. 2007 Aug. 246(2):246-53. [QxMD MEDLINE Link].
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007 Nov. 142(5):761-8. [QxMD MEDLINE Link].
van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010 Jan 14. 362(2):129-37. [QxMD MEDLINE Link].
Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery. 2007 Sep. 142(3):313-8. [QxMD MEDLINE Link].
Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD. Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer. Surgery. 2007 May. 141(5):610-8. [QxMD MEDLINE Link].
House MG, Gonen M, Jarnagin WR, DAngelica M, DeMatteo RP, Fong Y. Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer. J Gastrointest Surg. 2007 Nov. 11(11):1549-55. [QxMD MEDLINE Link].
Gallagher S, Zervos E, Murr M. Distal Pancreatectomy. Von Hoff, Evans, Hruban. Pancreatic Cancer. Sudbury, Mass: Jones and Bartlett; 2005. 20.
Muller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, et al. Is there still a role for total pancreatectomy?. Ann Surg. 2007 Dec. 246(6):966-74; discussion 974-5. [QxMD MEDLINE Link].
Kalser MH, Ellenberg SS. Pancreatic cancer. Adjuvant combined radiation and chemotherapy following curative resection. Arch Surg. 1985 Aug. 120(8):899-903. [QxMD MEDLINE Link].
Neoptolemos JP, Stocken DD, Friess H, Bassi C, Dunn JA, Hickey H. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med. 2004 Mar 18. 350(12):1200-10. [QxMD MEDLINE Link].
Yang R, Cheung MC, Byrne MM, Jin X, Montero AJ, Jones C, et al. Survival effects of adjuvant chemoradiotherapy after resection for pancreatic carcinoma. Arch Surg. 2010 Jan. 145(1):49-56. [QxMD MEDLINE Link].
Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007 Jan 17. 297(3):267-77. [QxMD MEDLINE Link].
Neuhaus P, Riess H, Post S. CONKO-001:Final results of the randomized, prospective multicenter phase III trial of adjuvant chemotherapy with gemcitabine versus observation in patients with resected pancratic cancer. J Clin Oncol. 2008. 26(15S):204s(abstract LBA4504).
Nelson R. Best Survival Ever in Resectable Pancreatic Cancer. Medscape Medical News. Available at https://www.medscape.com/viewarticle/897600. June 04, 2018; Accessed: January 10, 2020.
Wan G, Sun X, Li F, Wang X, Li C, Li H, et al. Survival Benefit of Metformin Adjuvant Treatment For Pancreatic Cancer Patients: a Systematic Review and Meta-Analysis. Cell Physiol Biochem. 2018 Sep 5. 49 (3):I. [QxMD MEDLINE Link]. [Full Text].
Vervenne W, Bennouna J, Humblett Y. A randomized double-blind, placebo (P) controlled, multicenter phase III trial to evaluate the efficacy and safety of adding bevacizumab (B) to erlotinib (E) and gemcitabine (G) in patients (pts) with metastatic pancreatic cancer. J Clin Oncol. 2008. 26(15S):214s(abstract 4507).
Loehrer P, Powell M, Cardenes H. A randomized phase III study of gemcitabine in combination with radiation therapy versus gemcitabine alone in patients with localized, unresectable pancreatic cancer:E4201. J Clin Oncol. 2008. 26(15S):214(abstract 4506).
Bernhard J, Dietrich D, Scheithauer W, Gerber D, Bodoky G, Ruhstaller T, et al. Clinical benefit and quality of life in patients with advanced pancreatic cancer receiving gemcitabine plus capecitabine versus gemcitabine alone: a randomized multicenter phase III clinical trial--SAKK 44/00-CECOG/PAN.1.3.001. J Clin Oncol. 2008 Aug 1. 26(22):3695-701. [QxMD MEDLINE Link].
Cunningham D, Chau I, Stocken DD, Valle JW, Smith D, Steward W, et al. Phase III randomized comparison of gemcitabine versus gemcitabine plus capecitabine in patients with advanced pancreatic cancer. J Clin Oncol. 2009 Nov 20. 27(33):5513-8. [QxMD MEDLINE Link].
Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011 May 12. 364(19):1817-25. [QxMD MEDLINE Link].
Conroy T, Hammel P, Hebbar M, et al, Canadian Cancer Trials Group and the Unicancer-GI–PRODIGE Group. FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. N Engl J Med. 2018 Dec 20. 379 (25):2395-2406. [QxMD MEDLINE Link]. [Full Text].
Wang-Gillam A, Li CP, Bodoky G, Dean A, Shan YS, Jameson G, et al. Nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabine-based therapy (NAPOLI-1): a global, randomised, open-label, phase 3 trial. Lancet. 2015 Nov 29. [QxMD MEDLINE Link].
[Guideline] U.S. Preventive Services Task Force. Final Recommendation Statement: Pancreatic Cancer: Screening. Available at https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/pancreatic-cancer-screening1. October 2019; Accessed: January 10, 2020.
American Academy of Family Physicians. Summary of Recommendations for Clinical Preventive Services. Leawood KS: American Academy of Family Physicians; November 2015. [Full Text].
Canto MI, Harinck F, Hruban RH, Offerhaus GJ, Poley JW, Kamel I, et al. International Cancer of the Pancreas Screening (CAPS) Consortium summit on the management of patients with increased risk for familial pancreatic cancer. Gut. 2013 Mar. 62 (3):339-47. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Goggins M, et al; International Cancer of the Pancreas Screening (CAPS) consortium. Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium. Gut. 2020 Jan. 69 (1):7-17. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Aslanian HR, Lee JH, Canto MI. AGA Clinical Practice Update on Pancreas Cancer Screening in High Risk Individuals: Expert Review. Gastroenterology. 2020 May 13. [QxMD MEDLINE Link].
[Guideline] Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, et al. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016 Jul 20. 34 (21):2541-56. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Balaban EP, Mangu PB, Khorana AA, Shah MA, Mukherjee S, Crane CH, et al. Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016 Aug 1. 34 (22):2654-68. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Sohal DP, Mangu PB, Khorana AA, Shah MA, Philip PA, O'Reilly EM, et al. Metastatic Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016 Aug 10. 34 (23):2784-96. [QxMD MEDLINE Link]. [Full Text].
[Guideline] eUpdate – Cancer of the Pancreas Treatment Recommendations. European Society for Medical Oncology. Available at https://www.esmo.org/guidelines/gastrointestinal-cancers/pancreatic-cancer/eupdate-cancer-of-the-pancreas-treatment-recommendations2. June 20, 2017; Accessed: October 6, 2021.
Kushi LH, Doyle C, McCullough M, Rock CL, Demark-Wahnefried W, Bandera EV, et al. American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2012 Jan-Feb. 62 (1):30-67. [QxMD MEDLINE Link].
Golan T, Hammel P, Reni M, Van Cutsem E, Macarulla T, Hall MJ, et al. Maintenance Olaparib for Germline BRCA-Mutated Metastatic Pancreatic Cancer. N Engl J Med. 2019 Jul 25. 381 (4):317-327. [QxMD MEDLINE Link].

Media Gallery

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.