Chapter 089. Pancreatic Cancer (Part 2)

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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 (Courvoisier's 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 (Virchow's node) may be involved with tumor, or widespread peritoneal disease may be palpable on rectal examination in the pouch of Douglas. Diagnostic Procedures Imaging 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) 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 (Courvoisier's 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 (Virchow's node) may be involved with tumor, or widespread peritoneal disease may be palpable on rectal examination in the pouch of Douglas. Diagnostic Procedures Imaging Studies
(Fig. 89-1) Ultrasound is often used as an initial investigation for patients with jaundice, or with less-specific symptoms such as upper abdominal discomfort, and is able to assess the biliary tract, gall bladder, pancreas, and liver. Computed tomography (CT) scanning is preferable to ultrasound even though it is more costly, as it is less operator-dependent, more reproducible, and less susceptible to interference from intestinal gas. The sensitivity and specificity of CT is markedly improved by the use of pancreatic protocol scanning on modern multislice scanners. CT may show a pancreatic mass, dilatation of the biliary system or pancreatic duct, or distal spread to the liver, regional lymph nodes, or peritoneum (and/or associated ascites). When helical CT is combined with the use of intravenous contrast, it may also help determine resectability by providing information on the involvement of important vascular structures such as the celiac axis, superior mesenteric or portal vessels. Endoscopic retrograde cholangiopancreatography (ERCP) is also widely used in the diagnosis of pancreatic cancer, particularly when CT and ultrasound fail to show a mass lesion, and may reveal either stricture or obstruction in either the pancreatic or common bile duct. ERCP can also be used to obtain brushings of a stricture for cytology or for 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 any advantages over CT in the routine evaluation of patients with possible pancreatic cancer, magnetic resonance cholangiopancreatography (MRCP) may be better than CT for defining the anatomy of the pancreatic duct and biliary tree, being able to image the ducts both above and below a stricture. The sensitivity of MRCP is comparable to ERCP, but does not require contrast administration to the ductal system, so that there is less associated morbidity. MRCP may be useful when cannulation of the pancreatic duct by ERCP has been unsuccessful or may be difficult, such as when normal anatomy is changed by surgery. Positron-emission 18 tomography with F-fluoro-2deoxyglucose (FDG-PET) may be useful for excluding occult distal metastasis in patients with localized disease who are being worked up for surgery or in patients with unresectable localized disease being considered for chemoradiotherapy. Figure 89-1