Keterangan
The diagnosis of cancer of the pancreas is difficult and often late. The symptoms are not terribly specific and this is why the diagnosis is often at an advanced stage. Symptoms include jaundice (yellowing of skin and whites of the eyes), light-colored stools, dark urine, pain in the upper or middle abdomen and or back, unexplained weight loss, feeling tired, and poor appetite. With the exception of jaundice and color of stools and urine, none of these symptoms and signs are specific indicators that something is wrong, and even these are often late signs of disease (meaning by the time they occur the cancer is Stage I or greater.) There is one brand new, promising blood marker (GPC1) that may be helpful for detection. The definitive diagnosis requires confirmation by radiologic studies and or tissue biopsy of cancerous tissue. Sometimes a gastroenterologist will discover the disease with endoscopic techniques. Pancreatic cancer has a very high mortality and the later it is diagnosed (more advanced the stage) the poorer the survival.
Ringkasan
- Pancreatic cancer is often called a silent killer due to its late-stage diagnosis. Despite being the 10th most common cancer in men and the 8th in women worldwide, it is the 4th leading cause of cancer death, accounting for approximately 7% of all cancer deaths. A significant percentage of patients, around 80%, present at an unresectable stage, making treatment challenging.
- The pancreas, a glandular structure in the gastrointestinal system, comprises the uncinate process, head, body, and tail. It sits within the duodenal C-loop. Blood supply to the pancreas comes from the superior mesenteric artery and branches of the celiac artery. Lymphatic drainage occurs through various nodes, including the peri-pancreatic, pancreaticoduodenal, and splenic nodes.
- Incidence rates vary slightly between men and women, with men experiencing higher rates likely due to lifestyle factors. Overall survival rates for pancreatic cancer are discouragingly low, with a five-year survival rate of around 10% for all patients. However, this rate increases to approximately 30% when the tumor is resectable. Median survival times differ significantly based on resectability, ranging from 6 to 18 months for unresectable tumors and less than 6 months for metastatic cases.
- Risk factors for pancreatic cancer include age, male gender, smoking, alcohol consumption, chronic pancreatitis, familial history, genetic abnormalities, obesity, and diabetes. Specific genetic syndromes, such as BRCA-associated cancers and MEN syndromes, also increase the risk. Dietary factors, like high-fat diets and smoked foods, are implicated, as is H. pylori infection.
- Pre-neoplastic lesions, such as pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms (MCNs), can potentially progress to cancer. Specific genes, including KRAS, CDKN2A, TP53, and SMAD4, are associated with invasive pancreatic cancer. Histological types include adenocarcinoma, acinar cell carcinoma, small cell carcinoma, and pancreatic neuroendocrine tumors (PNETs).
- Early stages are often asymptomatic, making early detection difficult. Common symptoms include significant weight loss, epigastric pain, and painless jaundice. New-onset diabetes in older individuals should raise suspicion. Patients may also exhibit pruritus, migratory thrombophlebitis (Trousseau's sign), and palpable gallbladder. In advanced cases, ascites can occur.
- Diagnosis relies on triple-phase CT scans, which involve early arterial, late arterial, and portal venous phases. Additional imaging modalities include MRI, endoscopic ultrasound (EUS), and PET/CT scans. Biopsy, typically performed via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), confirms the diagnosis. CA19-9 can be used for monitoring.
- Staging is based on the TNM system, focusing on tumor size (T1, T2, T3) and nodal involvement (N1, N2). However, resectability is a primary determinant of treatment strategy. Resectability is determined by the proximity of the tumor to arteries (celiac axis, superior mesenteric artery, common hepatic artery) and veins (superior mesenteric vein, portal vein). Encasement beyond 180 degrees deems a tumor unresectable.
- Management involves surgery, chemotherapy, and radiation therapy. For resectable tumors, surgery (Whipple procedure) is the primary treatment. Borderline resectable tumors often undergo neoadjuvant chemotherapy followed by reassessment for surgery. Unresectable tumors may be treated with chemotherapy and/or radiation therapy. Metastatic disease is managed with chemotherapy. Novel approaches include stereotactic body radiation therapy (SBRT) to focally target the tumor and arterial interfaces.
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