CARCINOMA OF THE PANCREAS - Diagnosis
Saturday, September 22nd, 2007Carcinoma of the pancreas must be considered in older patients with unexplained abdominal pain, excessive weight loss, the sudden onset of diabetes mellitus without obesity or appropriate family history, acute pancreatitis without a known risk factor (Table 42-2), or obstructive jaundice. Laboratory studies, including the serum tumor markers carcinoembryonic antigen (CEA), a-fetoprotein (AFP), and galactosyltrans-ferase isoenzyme II (GT-II), rarely help because of their nonspecificity.
The diagnosis is made most frequently by a combination of imaging and fine needle biopsy. Figure 42-6 provides an algorithm for using these modalities. The diagnostic sensitivity for carcinoma of the pancreas by these techniques is ultrasonography 70 to 90 per cent, CT approximately 80 per cent, and ERCP 75 to 85 per cent. Selective arteriography rarely may be required.
Treatment and Prognosis. The treatment of pancreatic carcinoma is inadequate and disappointing. Only about 10 to 20 per cent of tumors are resectable at the time of diagnosis, and surgical treatment of even this group produces no demonstrated increase in five-year survival. Surgery is often confined to palliative decompression of the biliary system to relieve obstructive jaundice or severe pruritus or cholangitis. This can now be effected in many patients by percutaneous transhepatic stenting of the common bile duct with internal or external drainage. Stents may be placed also during ERCP. Supravoltage radiation or multidrug chemotherapeutic programs may somewhat palliate symptoms but do not prolong survival. Approximately 10 per cent of patients survive diagnosis by one year and only 1 to 2 per cent by five years.
Complications. The complications of pancreatic carcinoma have largely been listed as part of the clinical manifestations. In addition, there may be extensive local invasion of vital structures and metastases, especially to the liver.