Tap icon
to view sections

Objectives

Objectives:

The following module was designed following the objectives of the Oncology Goals and Objectives for Medical Students for pancreatic cancer. Information on epidemiology, risk factors, prevention, screening, presentation, diagnosis, and prognosis for pancreatic cancer is provided.

By the end of the tutorial, the following objectives should be addressed:

  1. Understand basic anatomy of the pancreas
  2. Discuss the epidemiology of pancreatic cancer
  3. Identify common risk factors associated with pancreatic cancer
  4. Discuss pancreatic cancer prevention strategies
  5. Discuss the types of screening done to identify pancreatic cancer in an individual  
  6. Discuss the common presentation of pancreatic cancer in an individual
  7. Discuss how the diagnosis of pancreatic cancer is made
  8. Briefly discuss the classification, pathology, staging and treatment of pancreatic cancer
  9. Discuss the prognosis associated with pancreatic cancer

Anatomy

The pancreas is a glandular, mainly retroperitoneal organ. It has both exocrine function (production of digestive enzymes that are secreted into the duodenum via the pancreatic duct) and endocrine function (production of hormones such as insulin and glucagon).

Main Regions of the Pancreas:

  1. Head: widest part of the pancreas found within the C-shaped curve of the duodenum and lies to the right of the superior mesenteric vessels
  2. Uncinate Process: an extension of the head of the pancreas found inferior to the body of the pancreas and lies posterior to the superior mesenteric vein
  3. Neck: the thinnest part of the pancreas between the head and the body that lies anterior to the superior mesenteric vessels
  4. Body: the main region of the pancreas that is found posterior to the stomach and lies to the left of the superior mesenteric vessels
  5. Tail: the only part of the pancreas that is intraperitoneal and found between layers of the splenorenal ligament
Image 1. Main regions of the pancreas, labelled by colour.

Organs in Close Proximity:

  1. Stomach: lies anterior to the pancreas 
  2. Duodenum: surrounds the head of the pancreas in a “C” shape
  3. Transverse Colon: attaches to the anterior surface of the pancreas by the transverse mesocolon
  4. Common Bile Duct: lies posterior to the head of the pancreas, allowing bile to pass from the gallbladder to the duodenum. 
  5. Liver/Gallbladder: lies superior to the pancreas
  6. Spleen: attaches to the tail of the pancreas
Image 2 and 3. Organs in close proximity to the pancreas.

Vascular Supply:

The pancreas receives its blood supply from the pancreatic branches of the splenic artery. The head of the pancreas receives additional blood supply from the superior and inferior pancreaticoduodenal arteries (branches of the gastroduodenal and superior mesenteric arteries respectively).

There are also several vessels in the vicinity of the pancreas, including:

  1. Aorta and Inferior Vena Cava: lies posterior to the head of the pancreas
  2. Superior Mesenteric Artery and Vein: lies posterior to the neck of the pancreas and typically anterior to the uncinate process
  3. Hepatic Portal Vein: formed through the union of the splenic vein and superior mesenteric vein and is found posterior to the neck of the pancreas

This knowledge becomes particularly important when considering potential sources of hematogenous spread or in the case of determining tumor resectability. 

Image 4. Vascular supply of the pancreas as well as pertinent surrounding vessels.

Innervation:

The pancreas is innervated by three nerve bundles:

  1. Vagus Nerve
  2. Thoracic Splanchnic Nerves
  3. Celiac Plexus

The celiac plexus (also commonly known as the “solar plexus”) is a complex network of nerves located at T12 that surrounds the celiac trunk (arises from the aorta). It is responsible for transmitting the sensation of pain for the pancreas. In the case of pancreatic cancer, this region is often irritated by the presence of a growing mass, leading to severe and often refractory pain.

Epidemiology

Pancreatic cancer is a disease with a high mortality rate. In 2018, 5139 cases were reported in Canada, and 50 846 were reported in the United States. Worldwide, it is the eighth leading cause of cancer-related death in men and the ninth leading cause in women. Overall, it is the seventh cause of cancer-related death in the world.

The incidence of pancreatic cancer varies by sex and race. However, it tends to be greater in males than females (1:3:1) and in African Americans than in Caucasians. Incidence of pancreatic cancer does seem to be affected by geography, with the highest incidence seen in developed parts of the world, including North America, New Zealand and Hawaii. The lowest incidence is seen in India and Nigeria.

Pancreatic Cancer Epidemiology: Fast Facts

Statistics

Eighth leading cause of cancer-related death in men.
Ninth leading cause of cancer-related death in women.
Seventh leading cause of cancer-related death worldwide.

Geography

Highest Rates: Developed parts of the world, including North America, New Zealand and Hawaii
Lowest Rates: India, Nigeria

Median Age

70 years old (usually presents >45 years old)

Sex

Higher incidence in males than females, 1.3:1

Race

Higher incidence in African Americans

Risk Factors

Risk factors for pancreatic cancer can be separated into two categories: modifiable and non-modifiable. Modifiable risk factors imply the patient can take measures to change them and reduce their overall risk of pancreatic cancer. In total, modifiable risk factors make up 85-90% of all pancreatic cancer risk factors. The remaining 10-15% are deemed non-modifiable, implying they make up the innate risk a particular patient has for developing pancreatic cancer and cannot be changed.

Pancreatic Cancer Risk Factors

Modifiable

Chronic Pancreatitis (most common cause is long-term excessive alcohol consumption)
Smoking
Diabetes
Obesity and inactivity
There is some evidence that diet, caffeine consumption, H. Pylori, HBV/HCV may lead to the development of pancreatic cancer.

Non-modifiable

Genetic predisposition syndromes associated with pancreatic cancer such as BRCA1/2, Peutz-Jeghers syndrome, and HNPCC.
Familial Pancreatic Cancer (major gene involved not yet identified)
Cystic fibrosis
Pancreatic cysts

Prevention

The risk of pancreatic cancer can be reduced by addressing modifiable risk factors the patient has. Common ways of accomplishing this include:

  1. Smoking cessation
  2. Reduced alcohol consumption (one of the most common causes of chronic pancreatitis)
  3. Healthy lifestyle that includes physical activity and a balanced diet
  4. Good glycemic control and management of diabetes

Screening

The goal of pancreatic cancer screening is to detect pre-invasive and early invasive tumors in asymptomatic patients. Screening is typically reserved for patients with non-modifiable risk factors (such as genetic predispositions) and should only be done in patients who are good surgical candidates. 

Candidates for pancreatic cancer screening include:

  1. First-degree relatives of patients with Familial Pancreatic Cancer where there are at least two affected first-degree relatives in the family
  2. Patients who have Peutz-Jeghers syndrome 
  3. Patients who are carriers of a Lynch syndrome mutation and have one or more affected first-degree relatives
  4. Patients who are carriers of other specific mutations (Ex. BRACA1/2)
  5. Patients with hereditary pancreatitis

Screening typically begins at age 45-50, or 10-15 years prior to the youngest age of diagnosis of pancreatic cancer in the family. Imaging can be done annually until a lesion is detected or screening is no longer deemed appropriate (no longer a surgical candidate, decreased life expectancy, or patient no longer wishes to have screening). There are a number of different screening modalities that can be used which are discussed in the table below.

Screening Modalities

Ultrasound

Transabdominal:

  • Typically the first type of imaging done
  • Can be used to assess for a mass in the head of the pancreas and/or dilated bile ducts
  • Low sensitivity for small lesions.

Endoscopic:
  • Can be used if a mass is not detected transabdominally and there is suspicion of pancreatic involvement or tumor markers (CA19-9) are elevated.
  • Useful for detecting small lesions

Disadvantage of U/S: image can be obstructed by bowel gas

CT

Better than ultrasound at imaging masses, duct dilation and enlarged lymph nodes.
Used to image the abdomen and pelvis to determine the stage of the cancer and assess for metastasis.

Disadvantage of CT: patients are exposed to ionizing radiation.

MRI/MRCP

High sensitivity and specificity, with excellent visualization of the bile and pancreatic duct.
Used to image the abdomen and pelvis to determine the stage of the cancer and assess for metastasis.

Disadvantage of MRI/MRCP: not widely available and very expensive.

It is important to remember that the risks and benefits of screening must be discussed with the patient beforehand.

Pancreatic Cancer Screening Considerations

Risks

Benefits

1. Complications with invasive screening procedures (Ex. IV contrast)
2. Overdiagnosis and overtreatment
3. False-positives, leading to patient anxiety and unnecessary surgery

1. Early detection and higher probability of successful resection of the tumor/lesion
2. Cost-effective for high-risk patients

Presentation

Like most cancers, pancreatic cancer can spread in a local, lymphatic or hematogenous fashion. Signs and/or symptoms the patient presents with may provide information about the extent of cancer spread. However, the signs and symptoms of pancreatic cancer are often non-specific in nature and similar clinical findings may be present in both local and metastatic disease. As a result, we cannot use a patient’s clinical presentation alone to diagnose or stage pancreatic cancer.

Initially, patients are asymptomatic due to the small size of the pancreatic lesion. As the mass becomes larger and begins to spread, signs and symptoms become more apparent. The most common symptoms associated with pancreatic cancer are:

  1. Jaundice. Occurs when a mass localized to the head of the pancreas is in close proximity to the common bile duct, causing obstruction. This results in hyperbilirubinemia, which manifests as yellowing of the skin and membranes. It is often accompanied by pruritus, dark urine and pale stools. Note that there is no pain associated with this obstruction. Therefore, it is often described as painless jaundice and is the hallmark finding of pancreatic cancer. These symptoms worsen as the mass enlarges and spreads to the lymph nodes.
  2. Abdominal pain. Occurs when a mass localized to a region of the pancreas (often the tail) irritates the celiac plexus, transmitting the sensation of pain. Usually insidious in onset and presenting as a dull ache in the epigastric region of the abdomen. The pain can radiate under the ribs bilaterally as well as to the mid-back and/or shoulder. The pain may worsen with eating or lying supine. These symptoms worsen as the mass enlarges and spreads to the lymph nodes.
  3. Weight Loss. Usually the result of anorexia, satiety, and diarrhea secondary to mass effect and affected exocrine function. These symptoms are often present with higher disease burden, such as with hematogenous spread of the disease.

Other common signs/symptoms of pancreatic cancer are described in the tables below.

Symptoms of Pancreatic Cancer

Local

Lymphatic

Hematogenous

  • Abdominal Pain (79%)
  • Epigastric Pain (71%)
  • Back Pain (49%)
  • Dark Urine (59%)
  • Jaundice (56%)
  • Abdominal Pain (79%)
  • Epigastric Pain (71%)
  • Back Pain (49%)
  • Physical Weakness (86%)
  • Weight Loss (85%)
  • Anorexia (83%)
  • GI Symptoms:
    • Nausea (51%)
    • Vomiting (33%)
    • Diarrhea (44%)
    • Steatorrhea
Signs of Pancreatic Cancer

Local

Lymphatic

Hematogenous

  • Jaundice (56%)
  • Right Upper Quadrant Mass (15%)
  • Courvoisier’s Sign (13%) (nontender but palpable distended gallbladder at the right costal margin)
  • Epigastric Mass (9%)
  • Right Upper Quadrant Mass (15%)
  • Epigastric Mass (9%)
  • Hepatomegaly (39%)
  • Cachexia (13%)
  • Ascites (5%)

Diagnosis

As with any patient complaint, begin with a detailed history and a focused physical exam. 

The following are important aspects of a history for suspected pancreatic cancer:undefined

  1. History of presenting complaint (onset, duration, alleviating/aggravating factors, associated symptoms, etc)
  2. Complete medical history, including discussion of comorbid illnesses (ex. diabetes, chronic pancreatitis)
  3. Risk factor assessment, including tobacco and alcohol use, lifestyle, and family history
  4. Review of systems to assess for constitutional symptoms or other findings indicative of metastases

A physical exam should be done to find clinical signs of pancreatic cancer. A focused abdominal exam is appropriate, with emphasis on palpation of an epigastric or right upper quadrant mass (may or may not be tender) and other findings such as hepatomegaly or ascites. Extra-abdominal physical findings should also be assessed such as jaundice of the skin and/or membranes and weight loss (cachexia).

Absence of clinically significant findings on physical exam does not rule out the diagnosis of pancreatic cancer. If the history is suspicious for pancreatic cancer, initial diagnostic testing, such as laboratory investigations and imaging, are initiated.

Laboratory investigations may include:

  1. CBC, electrolytes, Cr/BUN
  2. Liver enzymes (ALT, AST, ALP, GGT) and bilirubin
  3. Serum lipase
  4. Tumour marker CA19-9

1. Carbohydrate Antigen 19-9 (also known as cancer-associated antigen 19-9) is a serum tumour marker that can be measured when a physician is suspicious their patient has pancreatic cancer
2. Sensitivity: 70-92%
3. Specificity: 68-92%

4.

Pros to CA19-9

Cons to CA19-9

  1. Specificity can be improved by using higher CA19-9 cutoffs (at the expense of sensitivity).
  2. Serum levels may have prognostic value and may be an indicator of disease activity.
  3. Serial monitoring is helpful in patients who have received potentially curative surgery or who are receiving chemotherapy.
  1. Sensitivity is related to tumour size, and decreases with smaller tumours.
  2. Specificity is low as CA19-9 can be elevated in patients with other types of cancer a well as benign pancreaticobiliary disorders.
  3. Patient must express the Lewis blood group antigen for CA19-9 to be expressed

Overall, the use of CA19-9 as a screening or diagnostic test is not recommended in expert-created guidelines and should be used with caution.

The imaging modality chosen will depend on the patient’s presenting symptoms:

A summary of these modalities can be found in the table below.

Diagnostic Modality

Indications

Ultrasound

First line diagnostic tool in cases of jaundice/abdominal pain to assess for biliary-pancreatic disease

CT

Used to:

  • Confirm positive US findings
  • Assess for small (sub-3cm) masses in cases where clinical picture is suspicious for pancreatic cancer
  • Gather a comprehensive local and metastatic disease assessment for treatment options and possible tumour resectability

MRI/MRCP

Often used to characterize pancreatic masses and delineate the pancreatic ductal system

EUS

Used to:

  • Detect pancreatic lesions, particularly small (sub-3cm) masses; excellent visualization from the stomach/duodenum
  • Collect specimens for histopathological diagnosis (EUS-FNA)
  • Evaluate cases of suspected chronic or autoimmune pancreatitis

ERCP

Used to:

  • Visualization of the biliary tree and pancreatic ducts
  • Cases of choledocholithiasis (diagnostic and therapeutic)
  • Specimen collection, but has been somewhat replaced by EUS-FNA due to higher success rate and lower risk of post-procedural complications

If a patient presents with painless jaundice, the imaging modality of choice is often a transabdominal ultrasound of the right upper quadrant to assess for causes of biliary-pancreatic disease. Ultrasound is beneficial in this case because of its wide availability and low-cost to the health care system. It also has a high sensitivity for detecting masses in the head of the pancreas and biliary tract dilation, both important findings to assess for in a patient presenting with jaundice.

If a patient presents with epigastric pain and weight loss, a transabdominal ultrasound of the epigastrium and right upper quadrant may be done initially. However, because these clinical findings are more sinister, the imaging modality of choice is typically a CT scan due to its higher sensitivity for detecting small masses (<3cm) and its ability to detect metastatic disease.

The “positive” findings of pancreatic cancer on transabdominal US include a hypoechoic mass, dilatation of the pancreatic duct, and dilatation of the bile duct. Note that these findings are typically in keeping with a mass in the head of the pancreas. Masses in the body/tail of the pancreas are harder to detect by US due to lack of biliary dilatation and bowel gas obstructing the view.

If a transabdominal U/S is considered positive, the presence of a mass needs to be confirmed by a CT scan and disease extent needs to be assessed. The CT scan alone may provide enough information about the disease and resectability that surgical intervention can be carried out without a biopsy to confirm the diagnosis of pancreatic cancer. However, if there is uncertainty about the diagnosis or resectability, a biopsy +/- additional procedures may be carried out. Biopsies can be done through endoscopic ultrasound guidance or percutaneously.

If a transabdominal U/S is negative despite clinical suspicions of pancreatic cancer, a CT scan must be done. If the patient has signs of cholestasis (elevated ALP, GGT, bilirubin), an ERCP may be done instead to assess for choledocholithiasis. If either is found to be negative, no additional testing is required and the physician must consider an alternative diagnosis for the patient’s symptoms.

It is important to remember that although this module presents a pancreatic mass as pancreatic cancer, there is a differential diagnosis of a pancreatic mass. This is presented in the table below.

Differential Diagnosis of a Pancreatic Mass

Cystic Mass

  1. Non-neoplastic Cysts
    • True cysts
    • Retention cyst
  2. Pancreatic Cystic Neoplasms
    • Intraductal Papillary Mucinous Neoplasm of the Pancreas
    • Serous Cystic Tumours
    • Mucinous Cystic Neoplasms

Solid Mass

  1. Primary Exocrine Pancreatic Cancer
  2. Pancreatic Neuroendocrine Tumour
  3. Lymphoma (rare)
  4. Metastatic Cancer (rare)
  5. Focal Chronic Pancreatitis
  6. Autoimmune Pancreatitis
  7. Periampullary Malignancy
    • Arising from the ampulla, duodenum, or bile duct (may be difficult to distinguish from a primary exocrine tumour due to location)

Classification, Pathology, Staging, Treatment

Once the diagnosis of pancreatic cancer has been made, classification of the presenting neoplasm is necessary. Exocrine pancreatic neoplasms (arising from ductal and acinar cells and their stem cells) make up more than 95% of all pancreatic neoplasms. The remaining percentage are endocrine pancreatic neoplasms (arising from islet cells) and will not be covered in detail in this module.

Exocrine pancreatic neoplasms can be separated into benign and malignant, and are summarized in the table below. Note that the literature mentions a “pre-malignant” classification, which focuses on the potential of a neoplasm to progress to malignancy. This is determined by degree of dysplasia (low or high grade) and does not represent a specific type of neoplasm.

Pancreatic Neoplasms

Benign

Serous Cystadenoma

Malignant

  1. Ductal Adenocarcinoma + Subtypes (85-90%)
  2. Intraductal Papillary Mucinous Neoplasms (IPMN) with an Associated Invasive Carcinoma (2-3%)
  3. Mucinous Cystic Neoplasms (MCN) with an Associated Invasive Carcinoma (1%)
  4. Acinar Cell Carcinoma (<1%)
  5. Pancreatoblastoma (<1%)
  6. Serous Cystadenocarcinoma (<1%)

A biopsy is required to characterize the pancreatic neoplasm. This can be accomplished percutaneously or by endoscopic ultrasound.

Pancreatic Mass Biopsy Methods

Method

Description

Percutaneous FNA Biopsy

Performed with US or CT guidance
Sensitivity depends on tumour size and operator expertise
Theoretical risk of intraperitoneal tumour cell seeding along needle path

Endoscopic US-guided FNA Biopsy

Considered to be the best modality for obtaining a tissue diagnosis
Sensitivity 90%, Specificity 96%
Decreased risk of intraperitoneal tumour cell seeding along needle path

Once the pancreatic neoplasm has been characterized, staging is necessary for treatment planning and prognosis. This is commonly accomplished by CT-scan, as it allows for both local and distant assessment of cancer spread. The preferred staging system for all pancreatic neoplasms is the Tumour, Node, Metastasis (TNM) System. AJCC Cancer Staging Manual, Eighth Edition, was used to summarize the following TNM staging for exocrine pancreatic neoplasms.

TX: primary tumor cannot be assessed
T0: no evidence of primary tumor
Tis: caarcinoma in situ
T1a: tumor ≤ 0.5cm in greatest dimension
T1b: tumor > 0.5cm and ≤ 1cm in greatest dimension
T1c: tumor > 1cm and ≤ 2cm in greatest dimension
T2: tumor > 2cm and ≤ 4cm in greatest dimension
T3: tumor > 4cm in greatest dimension
T4: tumor involves celiac axis, superior mesenteric artery, and/or common hepatic artery, regardless of size

NX: lymph nodes cannot be assessed
N0: no regional lymph node metastases
N1: metastasis in 1-3 regional lymph nodes
N2: metastasis in 4 or more regional lymph nodes

M0: no distant metastases
M1: distant metastases are present

Stage 0: Tis N0 M0
Stage IA: T1 N0 M0
Stage IB: T2 N0 M0
Stage IIA: T3 N0 M0
Stage IIB: T1-3 N1 M0
Stage III: T1-3 N2 M0 or T4 N0-2 M0
Stage IV:T1-4 N0-2 M1

The treatment options are discussed below briefly for completeness:

This is the only potentially curative treatment of pancreatic cancer. To be a candidate for surgical resection, the cancer needs to be limited to the pancreas, it cannot involve critical structures such as peripancreatic vessels, and it cannot have metastasized.
Surgical technique varies based on location of the tumour in the pancreas and is summarized in the table below.

Surgical Techniques for Resection of Pancreatic Tumor

Location

Technique

Type of Procedure

Head of the pancreas

Pancreaticoduodenectomy

  • Whipple procedure
  • Pylorus-preserving pancreaticoduodenectomy

Open or laparoscopic (comparable morbidity and mortality)

Body/tail of the pancreas

Distal pancreatectomy with splenectomy

Open or Laparoscopic (comparable morbidity and mortality)

These types of therapies are used in the neoadjuvant, adjuvant and palliative settings.

Neoadjuvant: In patients with borderline resectable disease (locally advanced, unresectable but NO metastasis), neoadjuvant therapy with radiation and/or chemotherapy can be used to attempt to downstage the cancer and improve the possibility of future surgery. Neoadjuvant therapy is also being considered as a therapy option for patients with potentially resectable disease. However, no study has demonstrated improved resectability/survival compared to surgery alone, and it therefore remains unclear if it provides benefit compared to the standard adjuvant therapy currently provided.

Adjuvant: In patients undergoing tumour resection, adjuvant therapy (postoperative) is routinely recommended due to evidence of significant survival benefit. Patients often undergo six months of therapy.

Palliative: In patients with metastatic pancreatic cancer, therapy is offered for pain and symptom management. Early consultation to Palliative Care should be considered, as it has been shown to improve clinical outcomes, quality of life, and may prolong survival.

Prognosis

Prognosis for patients with pancreatic cancer is poor. Even in cases where pancreatic tumors are completely resected and there is no nodal involvement, there is a high incidence of recurrence in the first few years post-treatment (poor five-year survival rate) and the majority of patients die from the disease.

However, it is important to remember that survival estimates are dynamic and can change based on how long the patient has survived to date. For example, a patient’s five-year survival rate may be 18% immediately after surgery/treatment due to the high incidence of recurrence in pancreatic cancer. However, if the patient has had no recurrence three years post-surgery, their survival estimate can increase up to 66% (a 66% chance of an additional two years of life, or a “conditional two-year survival”).

It is also important to note that prognosis appears to continuously improve after five years of survival. Between years 9-13 post-surgery, a patient’s risk of death due to pancreatic cancer decreases to 10% per year. After year 13, their risk of death decreases to 3% per year as late as 20 years post-surgery. Therefore, in some cases, long-term survival is possible for patients diagnosed with pancreatic cancer.

Overall, a patient’s prognosis can be affected by many factors, which are summarized in the table below.

Factors affecting prognosis in pancreatic cancer

Treatment factors

  • Surgical resection vs radiation/chemotherapy
  • Efficacy of neoadjuvant chemotherapy (borderline resectable pancreatic cancer)
  • Status of surgical margins (involved or uninvolved)
  • Pre- and post-operative serum CA19-9 level

Patient factors

  • Cigarette Smoking
  • Candidacy for surgical resection

Tumor factors

  • Location of the tumour (head vs tail)
  • Grade
  • Stage
  • Level of invasion:
    • Lymphovascular invasion
    • Microvessel invasion
    • Portal vein invasion

References

Anatomy

  1. Teach Me Anatomy: The Pancreas. (2018). Retrieved from: https://teachmeanatomy.info/abdomen/viscera/pancreas/
  2. Ken Hub Anatomy: Blood supply and innervation of the pancreas. (2020). Retrieved from:  https://www.kenhub.com/en/library/anatomy/blood-supply-and-innervation-of-the-pancreas
  3. Radiopedia: Pancreas. (2019). Retrieved from:  https://radiopaedia.org/articles/pancreas?lang=us
  4. Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 1056, Public Domain. Retrieved from:  https://commons.wikimedia.org/wiki/Gray%27s_Anatomy_plates?uselang=en-ca#/media/File:Gray1056.png

Epidemiology, Risk Factors, Prevention, Screening

  1. Epidemiology and Nonfamilial Risk Factors for Exocrine Pancreatic Cancer. (2019). Retrieved from: https://www.uptodate.com/contents/epidemiology-and-nonfamilial-risk-factors-for-exocrine-pancreatic-cancer?search=pancreatic%20cancer&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6
  2. WHO International Agency for Research on Cancer. All Cancers, Source: Globocan. (2018). Retrieved from: http://gco.iarc.fr/today/data/factsheets/cancers/39-All-cancers-fact-sheet.pdf
  3. WHO International Agency for Research on Cancer. Pancreatic Cancer, Source: Globocan. (2018). Retrieved from:
    http://gco.iarc.fr/today/online-analysis-map?v=2018&mode=population&mode_population=continents&population=900&populations=900&key=asr&sex=0&cancer=13&type=0&statistic=5&prevalence=0&population_group=0&ages_group%5B%5D=0&ages_group%5B%5D=17&nb_items=5&group_cancer=1&include_nmsc=1&include_nmsc_other=1&projection=natural-earth&color_palette=default&map_scale=quantile&map_nb_colors=5&continent=0&rotate=%255B10%252C0%255D
  4. Familial Risk Factors for Pancreatic Cancer and Screening of High-Risk Patients. (2020). Retrieved from: https://www.uptodate.com/contents/familial-risk-factors-for-pancreatic-cancer-and-screening-of-high-risk-patients?search=pancreatic%20cancer&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8#H10545155

Presentation, Diagnosis

  1. Ingledew, P. (!). Pancreatic Cancer Review Notes.
  2. Clinical Manifestations, Diagnosis, and Staging of Exocrine Pancreatic Cancer. (2019). Retrieved from: https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-staging-of-exocrine-pancreatic-cancer?search=pancreatic%20cancer&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
  3. Endoscopic Ultrasound-Guided Celiac Plexus and Ganglia Interventions. (2018). Retrieved from: https://www.uptodate.com/contents/endoscopic-ultrasound-guided-celiac-plexus-and-ganglia-interventions?search=celiac%20plexus&source=search_result&selectedTitle=1~17&usage_type=default&display_rank=1
  4. Lee, E.S., Lee, J.M. Imaging diagnosis of pancreatic cancer: A state-of-the-art review. World Journal of Gastroenterology. June 2014. 20(24): 7864-7877. DOI: 10.3748/wjg.v20.i24.7864. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069314/

Classification, Pathology, Staging, Treatment, Prognosis

  1. Clinical Manifestations, Diagnosis, and Staging of Exocrine Pancreatic Cancer. (2019). Retrieved from: https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-staging-of-exocrine-pancreatic-cancer?search=pancreatic%20cancer&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
  2. Supportive Care of the Patient with Locally Advanced or Metastatic Exocrine Pancreatic Cancer. (2019). Retrieved from: https://www.uptodate.com/contents/supportive-care-of-the-patient-with-locally-advanced-or-metastatic-exocrine-pancreatic-cancer?search=pancreas&topicRef=2501&source=see_link#H894173325
  3. 13. Overview of Surgery in the Treatment of Exocrine Pancreatic Cancer and Prognosis. (2019). Retrieved from: https://www.uptodate.com/contents/overview-of-surgery-in-the-treatment-of-exocrine-pancreatic-cancer-and-prognosis?search=pancreatic%20cancer&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H18
  4. Amin MB, Edge SB, Greene FL, et al, eds. AJCC cancer staging manual. 8th ed. New York: Springer-Verlag; 2017.
  5. Pathology of exocrine pancreatic neoplasms. (2019). Retrieved from: https://www.uptodate.com/contents/pathology-of-exocrine-pancreatic-neoplasms?search=pancreas&topicRef=2501&source=see_link
  6. Naito, Y., Ishikawa, H., Sadashima, E., Okabe, Y., Takahashi, K., Kawahara, R., Hisaka, T., Fukahori, M., Ushijima, T., Ishida, Y., Tanigawa, M., Mihara, Y., Nakayama, M., Kondo, R., Kusano, H., Takase, Y., Abe, H., Ogo, E., Okuda, K., Shimamatsu, K., Yano, H., Akiba, J."Significance of neoadjuvant chemoradiotherapy for borderline resectable pancreatic head cancer: Pathological local invasion and microvessel invasion analysis". Molecular and Clinical Oncology 11.3 (2019): 225-233. Retrieved from: https://www.spandidos-publications.com/10.3892/mco.2019.1885?text=fulltext
  7. Initial chemotherapy and radiation for nonmetastatic, locally advanced, unresectable and borderline resectable, exocrine pancreatic cancer. (2019). Retrieved from: https://www.uptodate.com/contents/initial-chemotherapy-and-radiation-for-nonmetastatic-locally-advanced-unresectable-and-borderline-resectable-exocrine-pancreatic-cancer?search=treatment%20of%20pancreatic%20cancer&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2697730512
  8. Chemotherapy for advanced exocrine pancreatic cancer. (2020). Retrieved from: https://www.uptodate.com/contents/chemotherapy-for-advanced-exocrine-pancreatic-cancer?search=treatment%20of%20pancreatic%20cancer&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2


Whiteboard Videos

Coming soon