Chapter 089. Pancreatic Cancer (Part 2)

Physical Findings Patients with early disease may not have any significant abnormalities detectable on physical examination. Jaundice may be a presenting feature in some; in these patients a palpable, nontender gallbladder (Courvoisiers sign) may be palpated under the right costal margin. Patients with more advanced disease may have an abdominal mass, hepatomegaly, splenomegaly, or ascites. The left supraclavicular lymph node (Virchows node) may be involved with tumor, or widespread peritoneal disease may be palpable on rectal examination in the pouch of Douglas.Diagnostic ProceduresImaging Studies(Fig. 89-1) Ultrasound is often used as an initial investigation for patients with jaundice, or with...
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Chapter 089. Pancreatic Cancer (Part 2) Chapter 089. Pancreatic Cancer (Part 2) Physical Findings Patients with early disease may not have any significant abnormalitiesdetectable on physical examination. Jaundice may be a presenting feature in some;in these patients a palpable, nontender gallbladder (Courvoisiers sign) may bepalpated under the right costal margin. Patients with more advanced disease mayhave an abdominal mass, hepatomegaly, splenomegaly, or ascites. The leftsupraclavicular lymph node (Virchows node) may be involved with tumor, orwidespread peritoneal disease may be palpable on rectal examination in the pouchof Douglas. Diagnostic Procedures Imaging Studies (Fig. 89-1) Ultrasound is often used as an initial investigation for patientswith jaundice, or with less-specific symptoms such as upper abdominaldiscomfort, and is able to assess the biliary tract, gall bladder, pancreas, and liver.Computed tomography (CT) scanning is preferable to ultrasound even though it ismore costly, as it is less operator-dependent, more reproducible, and lesssusceptible to interference from intestinal gas. The sensitivity and specificity ofCT is markedly improved by the use of pancreatic protocol scanning on modernmultislice scanners. CT may show a pancreatic mass, dilatation of the biliarysystem or pancreatic duct, or distal spread to the liver, regional lymph nodes, orperitoneum (and/or associated ascites). When helical CT is combined with the useof intravenous contrast, it may also help determine resectability by providinginformation on the involvement of important vascular structures such as the celiacaxis, superior mesenteric or portal vessels. Endoscopic retrogradecholangiopancreatography (ERCP) is also widely used in the diagnosis ofpancreatic cancer, particularly when CT and ultrasound fail to show a mass lesion,and may reveal either stricture or obstruction in either the pancreatic or commonbile duct. ERCP can also be used to obtain brushings of a stricture for cytology orfor placing stents in order to relieve obstructive jaundice. Endoscopic ultrasound(EUS) may be useful in the diagnosis of small lesions (disease (see below). While magnetic resonance imaging (MRI) does not offer anyadvantages over CT in the routine evaluation of patients with possible pancreaticcancer, magnetic resonance cholangiopancreatography (MRCP) may be betterthan CT for defining the anatomy of the pancreatic duct and biliary tree, beingable to image the ducts both above and below a stricture. The sensitivity of MRCPis comparable to ERCP, but does not require contrast administration to the ductalsystem, so that there is less associated morbidity. MRCP may be useful whencannulation of the pancreatic duct by ERCP has been unsuccessful or may bedifficult, such as when normal anatomy is changed by surgery. Positron-emission 18tomography with F-fluoro-2deoxyglucose (FDG-PET) may be useful forexcluding occult distal metastasis in patients with localized disease who are beingworked up for surgery or in patients with unresectable localized disease beingconsidered for chemoradiotherapy. Figure 89-1