- Aggressive
- Early advanced local or distant spread
- Perivascular, perineurial and lymphatic spread
- Early spread to liver and peritoneum
- At time of diagnosis, only 10% cases surgically resectable
- 5 year survival rate <5%
- Radical pacreaticoduodenectomy – severe morbidity and mortality
- Weight loss, anorexia common symptoms
- Obstructive jaundice seen in tumors involving head of pancreas
- CA 19-9 is associated, but is neither sensitive nor specific
Imaging
- USG is first line investigation due to widespread availability. It is very useful to pick up obstructive jaundice. Masses may or may not be seen.
- Contrast enhanced oral water CT is the investigation of choice
- ERCP should not be done prior to any imaging as it reduces the ability of scans to pick up small tumors
- Endoscopic USG helps in biopsy of equivocal non obstructing lesions
- PET has limited role in initial diagnosis, but high accuracy in identifying local recurrence
- 70% in head or uncinate process
- Tumor is hypo echoic on US
- Poorly enhancing area in dynamic contrast enhanced CT. 11% tumors are iso dense.
- Earlier fixed delay technique of scanning at 40 sec with 4ml/s flow rate was used. Now it is replaced by bolus tracking and aorta +25 sec.
- Upstream main pancreatic duct dilatation and secondary pancreatic atrophy may be seen
- Uncinate process tumors – often don’t present with jaundice, spread along superior mesenteric artery, perineurial and even obstruct duodenum
Direct sign
- Hypo attenuating mass lesion
Indirect signs
- Biliary duct dilatation
- Pancreatic duct dilatation
- Double duct sign
- Focal gland atrophy
- Distorted contour of gland
- Loss of pancreatic lobulation
Staging
| TX | Primary tumor cannot be assessed |
| T0 | No evidence of primary tumor |
| Tis | Carcinoma in situ |
| T1 | Tumor ≤2 cm in greatest dimension |
| T2 | Tumor >2 cm, but ≤4 cm in greatest dimension |
| T3 | Tumor >4 cm in greatest dimension |
| T4 | Tumor involves celiac axis, superior mesenteric artery and/or common hepatic artery |
| NX | Regional lymph nodes cannot be assessed |
| N0 | No regional lymph nodes |
| N1 | Regional (peripancreatic) lymph node metastases |
| M0 | No distant metastasis |
| M1 | Distant metastasis |
- Perineurial spread and perivascular invasion suggest unresectability
- Tumor-vessel contact >180 degrees indicates venous involvement
- Tumor-vessel contact >180 degrees AND vessel irregularity or stenosis indicates arterial involvement
- Tear drop deformity sign: the fibrotic tumor when abutting the superior mesenteric or portal vein deforms the venous contour
- Stomach and duodenum involvement demonstrated with loss of normal enhancement of their wall
- Order of lymph node involvement: peripancreas, celiac, common hepatic, mesenteric, para aortic
- Tumor recurrence: often around superior mesenteric artery either as a mass or a cuff-like formation