Gastroenterology

Gastroenterology

Volume 117, Issue 6, December 1999, Pages 1464-1484
Gastroenterology

American Gastroenterological Association
AGA technical review on the epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma

https://doi.org/10.1016/S0016-5085(99)70298-2Get rights and content

Abstract

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee in March 1999 and by the AGA Governing Board in May 1999.

GASTROENTEROLOGY 1999;117:1464-1484

Section snippets

Literature review methods

We included only studies published after 1980. A literature search was initiated using MEDLINE and the medical subject terms pancreatic cancer with the cross-references epidemiology, diagnosis, chemotherapy, radiotherapy, and surgery. Secondary searches were also performed for each major category.

For epidemiology, secondary searches were undertaken using pancreatic cancer. To ascertain the national incidence of pancreatic cancer in the United States, we used cancer statistics from the National

Populations at risk for developing pancreatic cancer

Early diagnosis of cancer has been thwarted because populations at risk for developing pancreatic cancer have not been identified until recently. Although there is some debate about the risk of pancreatic cancer in patients with chronic pancreatitis, the strongest evidence for this association is in hereditary pancreatitis. In this disease, the estimated cumulative risk of pancreatic cancer to age 70 is 40%, but the estimated cumulative risk for developing pancreatic cancer in patients with a

Symptoms and signs

The suspicion of pancreatic cancer arises because of symptoms of pain, jaundice, anorexia, early satiety, or weight loss. Some symptoms may predict tumor location37 and prognosis.38 Painless jaundice is the most common presentation in patients with a potentially resectable and curable lesion (52% of patients with a resectable lesion). However, pain is the most frequent symptom (80% of all patients) and is present in 80% and 85% of patients with locally unresectable and advanced cancer,

Preoperative management

All patients undergoing pancreatic surgery require preoperative optimization of cardiac, pulmonary, and renal function, which is usually done in the outpatient setting. Although patients often have lost weight, the nutritional status of most is satisfactory enough for them to undergo surgery safely. However, if the serum albumin concentration is <3 g/dL or surgery is delayed for more than several weeks, supplemental enteral nutrition is indicated. Pancreatic enzyme replacement also should be

Epidemiology

Pancreatic cancer is deadly; overall 5-year survival is <5%. However, 5-year survival rates of >20% may accompany resection of “early tumors,” defined as tumors that measure ≤2 cm and are confined to the pancreas. Identification of patients with early cancer in populations at risk for developing pancreatic cancer should increase 5-year survival. At present, patients with idiopathic and alcoholic chronic pancreatitis and new-onset diabetes mellitus (<2 years, no family history, age >50 years)

Future research

Improving survival of pancreatic cancer patients depends on identification of patients who are at risk for developing pancreatic cancer, detection of disease at an early curable stage, and elucidation of the basic mechanisms of differentiation and transformation involved in pancreatic carcinogenesis that will lead to development of effective treatment to prevent or counteract these abnormalities. The best lead for early identification of pancreatic cancer is exploration of genetic and other

References (195)

  • H Iguchi et al.

    Analysis of the K-ras codon mutations in duodenal juice: possible application of a secretin test as a diagnostic tool for pancreatic cancers

    Gastroenterology

    (1996)
  • M Tada et al.

    Analysis of K-ras gene mutation in hyperplastic duct cells of the pancreas without pancreatic disease

    Gastroenterology

    (1996)
  • JA Rivera et al.

    Analysis of K-ras oncogene mutations in chronic pancreatitis with ductal hyperplasia

    Surgery

    (1997)
  • KJ Chang et al.

    The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma

    Gastrointest Endosc

    (1997)
  • MJ Wiersema et al.

    Endosongraphy-guided fine needle aspiration biopsy: diagnostic accuracy and complication assessment

    Gastroenterology

    (1997)
  • PC Freeny et al.

    Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography

    Am J Surg

    (1993)
  • HA. Pitt

    Curative treatment for pancreatic neoplasms. Standard resection

    Surg Clin North Am

    (1995)
  • HA Reber et al.

    Curative treatment for pancreatic neoplasms

    Surg Clin North Am

    (1995)
  • SL Parker et al.

    Cancer statistics 1996

    CA Cancer J Clin

    (1996)
  • A Riela et al.

    Increasing incidence of pancreatic cancer among women in Olmsted County, Minnesota, 1940 through 1988

    Mayo Clin Proc

    (1992)
  • JE Niederhuber et al.

    Base report on pancreatic cancer

    Cancer

    (1995)
  • AB Lowenfels et al.

    Hereditary pancreatitis and the risk of pancreatic cancer

    J Natl Cancer Inst

    (1997)
  • DC Whitcomb et al.

    Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene

    Nat Genet

    (1996)
  • AB Lowenfels et al.

    Pancreatitis and the risk of pancreatic cancer

    N Engl J Med

    (1993)
  • K Ohashi et al.

    ERCP and imaging diagnosis of pancreatic cancer

    Gastrointest Endosc

    (1997)
  • JA Rivera et al.

    Pancreatic mucinous ductal ectasia and intraductal papillary neoplasms. A single malignant clinicopathologic entity

    Ann Surg

    (1997)
  • RK McDowell et al.

    Mucinous ductal ectasia of the pancreas

    J Comput Assist Tomogr

    (1997)
  • F Sessa et al.

    Intraductal papillary-mucinous tumours represent a distinct group of pancreatic neoplasms: an investigation of tumour cell differentiation and K-ras, p53 and c-erbB-2 abnormalities in 26 patients

    Virchows Arch

    (1994)
  • L Gullo et al.

    Diabetes and the risk of pancreatic cancer

    N Engl J Med

    (1994)
  • J Permert et al.

    Islet amyloid polypeptide in patients with pancreatic cancer and diabetes

    N Engl J Med

    (1994)
  • SS Schwarts et al.

    A prospective study of glucose intolerance, insulin, C-peptide, and glucagon in patients with pancreatic carcinoma

    Am J Dig Dis

    (d1978)
  • J Everhart et al.

    Diabetes mellitus as a risk factor for pancreatic cancer

    JAMA

    (1995)
  • P Ghadirian et al.

    Reported family aggregation of pancreatic cancer within a population-based case-control study in the Francophone community in Montreal, Canada

    Int J Pancreatol

    (1991)
  • HT Lynch et al.

    Familial pancreatic cancer: clinicopathologic study of 18 nuclear families

    Am J Gastroenterol

    (1990)
  • FM Giardiello et al.

    Increased risk of thyroid and pancreatic carcinoma in familial adenomatous polyposis

    Gut

    (1993)
  • HT Lynch et al.

    Pancreatic cancer and the familial atypical multiple mole melanoma

    Pancreas

    (1991)
  • AM Goldstein et al.

    Increased risk of pancreatic cancer in melanoma-prone kindreds with p16INK4 mutations

    N Engl J Med

    (1995)
  • C Patrianakos et al.

    Chemical studies on tobacco smoke LXIV. On the analysis of aromatic amines in cigarette smoke

    J Anal Toxicol

    (1979)
  • TM Mack et al.

    Pancreas cancer and smoking, beverage consumption and past medical history

    J Natl Cancer Inst

    (1986)
  • RT Falk et al.

    Life-style risk factors for pancreatic cancer in Louisiana: a case-control study

    Am J Epidemiol

    (1988)
  • PK Mills et al.

    Dietary habits and past medical history as related to fatal pancreas cancer risk among Adventists

    Cancer

    (1988)
  • SE Norell et al.

    Diet and pancreatic cancer: a case-control study

    Am J Epidemiol

    (1986)
  • T Sugimura et al.

    Mutagens-carcinogens in foods

    Cancer Res

    (1983)
  • MJ Appel et al.

    Dietary fish oil (MaxEPA) enhances pancreatic carcinogenesis in azaserine-treated rats

    Br J Cancer

    (1996)
  • TM. Mack

    Pancreas

  • RT Falk et al.

    Occupation and pancreatic cancer risk in Louisiana

    Am J Intern Med

    (1990)
  • KA Steinmetz et al.

    Vegetables, fruit, and cancer. I. Epidemiology

    Cancer Causes Control

    (1991)
  • KA Steinmetz et al.

    Vegetables, fruit, and cancer. II. Mechanisms

    Cancer Causes Control

    (1991)
  • MH Kalser et al.

    Pancreatic cancer. Assessment of prognosis by clinical presentation

    Cancer

    (1985)
  • A Mannell et al.

    Factors influencing survival after resection for ductal adenocarcinoma of the pancreas

    Ann Surg

    (1986)
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