Pancreatic Carcinoma

A 74-year-old man had vague abdominal pain, jaundice, pruritus, gray stools, and dark urine. A painless, palpable mass in his right upper quadrant was found at examination.

Laboratory tests. The asparate aminotransferase level was 3220 U/L; serum alanine aminotransferase, 1527 U/L; alkaline phosphatase, 152 U/L; total bilirubin, 13 mg/dL; and direct bilirubin, 7.8 mg/dL. Prothrombin time was 20.5 seconds; INR was 3.43. Amylase and lipase levels were normal.

A computed tomography (CT) scan of the abdomen showed a hypoechoic mass in the region of the head of the pancreas. Endoscopic retrograde cholangiopancreatography demonstrated the double-duct sign—concurrent dilation of the main pancreatic duct and the adjacent common bile duct. A stent was placed in the bile duct to ensure good flow. Biopsy of the duct revealed adenocarcinoma.

Discussion. As many as 95% of malignant tumors of the pancreas are ductal adenocarcinomas. Because the diagnosis usually is not made until the disease has advanced, the prognosis is poor. Pancreatic ultrasonography or contrast-enhanced CT can detect the hypoechoic or low-density mass, which most often occurs in the head of the pancreas. Even small tumors in the pancreas head or uncinate can encroach on the bile duct and cause jaundice. Tumors in the organ’s body and tail develop asymptomatically; pain occurs when the neoplasm grows and involves the parapancreatic nerves.

A CT scan can reveal secondary signs of pancreatic cancer, which include the double-duct sign and atrophy of the distal gland.¹ Extrinsic compression of the bile duct by a malignancy can lead to bile and pancreatic duct strictures and obstructive jaundice.² A biopsy may be needed to differentiate a pancreatic neoplasm from focal pancreatitis. Jaundice is the most common initial physical finding; hepatomegaly and a palpable gallbladder also may be detected. Patients with advanced disease can have cachexia; muscle wasting; and a nodular liver, which is consistent with metastatic disease. Other physical findings in patients with disseminated pancreatic cancer may include left supraclavicular adenopathy (Virchow node), periumbilical lymphadenopathy (Sister Mary Joseph nodule), and drop metastases in the pelvis that encircle the perirectal region (Blumer shelf).³ [Editor’s note: See page 776 for a photograph of a Sister Mary Joseph nodule in another patient.]

Laboratory studies in patients with cancer of the head of the pancreas typically reveal elevated levels of serum total bilirubin, alkaline phosphatase, γ-glutamyl transpeptidase, and the hepatic aminotransferases. Routine laboratory values usually are normal in patients with early-stage localized cancer of the body and tail of the pancreas. Most patients with carcinoma of the pancreas have neither hyperamylacemia nor hyperlipasemia.

Assess coagulation parameters in patients with deep jaundice. Prolonged exclusion of the bile from the gastrointestinal tract leads to malabsorption of fatsoluble vitamins with decreased hepatic production of vitamin-K–dependent clotting factors.

References:

1. Juhl JH, Crummy AB, Kuhlman JE, Paul LW, eds. Paul and Juhl’s Essentials of Radiologic Imaging. 7th ed. Philadelphia: Lippincott-Raven; 1998:543. 
2. Lee JG. Unusual ERCP appearance of obstructive jaundice caused by pancreatic cancer. Gastrointest Endosc. 1996;44:757-758. 
3. Townsend CM, Beauchamp RD, Evers M, et al, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia: WB Saunders Company; 2001:1134-1135. (Case and photograph courtesy of Drs Mubashir Shah and Roderick Remoroza.)