Symptoms of pancreatic cancer.
1. Abdominal discomfort: About 60% of patients have upper abdominal discomfort in the early stage, which is easily confused with the symptoms of gastrointestinal and hepatobiliary diseases.
Abdominal pain: About 40% to 70% of patients with pancreatic cancer have abdominal pain as the most presenting symptom. The causes of abdominal pain include: (1) strong contraction of the pancreaticobiliary duct due to obstruction of its outlet, and abdominal pain is mostly paroxysmal and located in the upper abdomen; (2) visceral neuralgia caused by increased pressure in the bile duct or pancreatic duct, which is manifested as dull pain in the upper abdomen, aggravated one to two hours after meals and reduced after several hours; (3) the pancreas is richly innervated. The nerve fibers mainly come from the celiac plexus, the left and right celiac nerve nodes, and the superior mesenteric plexus, and the nociceptive nerve is located in the sympathetic nerve. If the tumor infiltrates and compresses these nerve fiber plexuses, it can cause low back pain, and the degree is intense, and the patient often takes a sitting position or lies on his back side all night long, which is mostly a late manifestation.
Jaundice: Painless jaundice is the most prominent symptom of pancreatic head cancer, accounting for about 30%. As pancreatic cancer has the biological characteristic of peritubular infiltration, jaundice can appear early, but it is not an early symptom. The color of stool becomes lighter as jaundice deepens, and finally becomes clay-colored, and the color of urine becomes more and more thick and soy sauce-colored.
4, gastrointestinal symptoms: most patients have a loss of appetite, aversion to greasy food, nausea, vomiting, indigestion and other symptoms.
5. Wasting and weakness: due to reduced food intake, indigestion and tumor consumption.
6.Fever: Most of the patients have different degrees of fever during the disease, and intermittent low fever is often not noticed. Chills and high fever may occur in case of biliary tract infection.
7.Thrombophlebitis: It is a special manifestation of pancreatic cancer, about 15%-25% of patients have thrombophlebitis during the disease, most commonly thrombophlebitis in the lower limbs.
What is the need for prompt medical consultation?
Early stage pancreatic cancer mostly has no specific symptoms and signs, and laboratory and other test results also lack specificity, so diagnosis and treatment are often delayed. In order to make early diagnosis, patients over 40 years of age who have recently developed the following clinical manifestations should be promptly consulted and the possibility of pancreatic cancer should be considered.
1.If there is any upper abdominal pain or persistent upper abdominal or low back pain of unknown origin.
2.Anorexia and wasting for unknown reasons.
3.Progressive obstructive jaundice of unknown origin.
4.Fatty diarrhea.
5.Recurrent episodes of pancreatitis.
6. Melancholic psychosis without obvious cause.
7.Symptoms of suspected pancreatic cancer and recent onset of diabetes mellitus.
8.Unexplained thrombophlebitis of the lower limbs.
Various examination methods and precautions.
1.Physical examination: The purpose of physical examination is to check whether there is jaundice visible to the naked eye, left supraclavicular lymph node metastasis, and to check some symptoms related to it, such as large liver, enlarged gallbladder, and upper abdominal masses.
2.Laboratory tests.
1) General laboratory tests: In cases of pancreatic head cancer, serum bilirubin may be significantly increased due to obstruction of the lower biliary tract, mainly due to increased direct bilirubin content, and others such as elevated serum amylase and elevated fasting glucose, but they are not specific.
2) Special laboratory tests: In recent years, domestic and international efforts have been made to find pancreatic cancer-specific antigen substances, such as carcinoembryonic antigen (CEA), pancreatic embryonic antigen (POA), pancreatic cancer-associated antigen (PCAA), CA19-9, pancreatic cancer-specific antigen (PaA) and leukocyte adhesion inhibition test (LAIT), among which CA19-9 has a higher positivity rate. Although the various antigens used in clinical practice have a certain positive rate for pancreatic cancer, they are not specific and can only be used for clinical reference. The Pancreatic Cancer Diagnostic and Treatment Center of Huashan Hospital found that the sensitivity and specificity of pancreatic cancer diagnosis can be significantly improved by combining four pancreatic cancer markers, including CA19-9, CA242, CA724 and CA125, which can be used as screening tests for pancreatic cancer in combination with B-ultrasound and CT.
3.Imaging examinations.
1) Ultrasound: It is the preferred examination method for patients suspected of pancreatic cancer. This method can detect the expansion of the biliary system at an early stage and also the expansion of the pancreatic duct, and it is possible to detect tumors with a diameter of 1 cm or more, and it is more likely to detect tumors with a diameter of 2 cm. The benefits of this method are not only safe, non-invasive and convenient, but also can be repeatedly followed up several times. For patients in high-risk age group, those who have epigastric discomfort, unexplained weight loss and loss of appetite can be screened by this method, and if they are found suspicious but not sure, further CT examination can be done.
2) CT: CT can be used as the first diagnostic tool for patients suspected of pancreatic cancer, and its diagnostic accuracy is higher than that of B-ultrasound, with a diagnostic accuracy of more than 80%. It can detect pancreatic bile duct dilatation and tumors of any part of the pancreas with a diameter of 1 cm or more, and it can also detect retroperitoneal lymph node metastasis, intrahepatic metastasis and observe whether there is retroperitoneal cancer infiltration, which can help determine whether the tumor can be removed before surgery. In recent years, Huashan Hospital has applied spiral CT to the diagnosis and preoperative staging of pancreatic cancer with high accuracy, and through three-dimensional imaging reconstruction method, clear images of three-dimensional and 360-degree rotation can be obtained, thus improving the reliability of preoperative staging diagnosis.
3) Magnetic resonance imaging (MRI): It can detect pancreatic tumors larger than 2 cm, but the overall imaging detection effect is not better than CT. magnetic resonance angiography (MRA) combined with three-dimensional imaging reconstruction method can provide clear images with 360 degrees of rotation and can replace angiography. MRCP (magnetic resonance cholangiopancreatography) can partially replace invasive ERCP (transendoscopic retrograde cholangiopancreatography), which can help to detect pancreatic head cancer. It helps to detect pancreatic head cancer.
4) X-ray: Barium duodenal hypotension angiography can detect images of duodenum infiltrated and pushed by cancer of the head of pancreas. The sensitivity and accuracy of ERCP for pancreatic cancer diagnosis can reach 95%, because it is an invasive test, so it is only used when ultrasound and CT cannot confirm the diagnosis, and ERCP can also collect pancreatic fluid or brush cells for examination. Positron emission tomography (PET) also has a high detection rate for pancreatic cancer, but unfortunately, the test is expensive.
5) Radionuclide pancreatic imaging: using 75Se-methionine as pancreatic imaging agent has some diagnostic value for larger pancreatic cancer.
4) Other examinations.
1) Pancreatic ductoscopy: With the continuous development of endoscopic technology, pancreatic ductoscopy has entered into clinical application in recent years. It can directly enter the lumen of pancreatic duct for observation, and collect pancreatic fluid and exfoliated cells for analysis and detection of K-ras gene.
2) Fine needle aspiration cytology: Fine needle aspiration cytology examination under the guidance of B-ultrasound or CT, more than 80% can obtain correct diagnosis.
Various treatment methods with advantages and disadvantages.
1.Surgical treatment.
Radical surgery: It is still the only effective cure for pancreatic cancer, but the surgery is complicated, traumatic and has high complication rate.
Pancreatic head cancer: There are mainly pancreaticoduodenectomy (Whipple procedure), pancreaticoduodenectomy with preservation of stomach and pylorus (PPPD procedure) and expanded pancreaticoduodenectomy. Whipple procedure is the most classic radical surgery for pancreatic head cancer, which generally includes the distal part of stomach, duodenum, head of pancreas and lower bile duct, and clears the anterior and posterior pancreatic head, around superior mesenteric artery, root of transverse colon mesentery, and lymph nodes around common hepatic artery and within hepatoduodenal ligament. In addition, it is not necessary to perform partial gastrectomy, and the duodenojejunostomy is simpler and shortens the operation time. However, some scholars believe that this procedure is not sufficient for subpyloric and perihepatic artery lymph node dissection, which may affect the postoperative effect, therefore, it is advocated only for small pancreatic head carcinoma, the bulb of duodenum and pylorus are not invaded; in addition, a small number of patients can be found to have gastric retention after this procedure clinically. In the past, many scholars took whether the tumor invaded the mesenteric vessels and portal vein as a marker to determine whether the pancreatic cancer could be resected or not, so the resection rate was low. With the improvement of surgical methods and techniques as well as perioperative management in recent years, an extended pancreaticoduodenectomy is performed for those with partial involvement of the superior mesenteric vessels and portal vein, in which the tumor and the involved vessels are removed together and the vascular access is reconstructed with autologous or artificial vessels. However, it is debated whether this procedure can improve the survival rate. Expanded pancreaticoduodenectomy should be chosen with caution because of its high trauma, long duration, and high technical requirements, which may increase the incidence of complications.
Pancreatic body and tail cancer: There are simple pancreatic body and tail resection, expanded pancreatic body and tail resection, and combined organ resection.
Total pancreatectomy: The total pancreatectomy procedure for pancreatic cancer is based on the multicenter pathogenesis theory of pancreatic cancer. Total pancreatectomy fundamentally eliminates the possibility of pancreatic leakage complications after pancreaticoduodenectomy, but there are sequelae such as diabetes mellitus and impaired digestion and absorption due to pancreatic exocrine insufficiency. Studies have shown that the near and long-term outcomes of total pancreatectomy have no significant advantages, so the indications should be strictly controlled, and only total pancreatic cancer is an absolute indication.
Internal drainage surgery.
Single bypass surgery: bile-intestinal anastomosis, mainly gallbladder-duodenal anastomosis, gallbladder-jejunostomy and common bile duct-jejunostomy. The advantages are that it can drain bile, relieve jaundice and prepare for radiotherapy; the disadvantage is that some patients may develop duodenal obstruction in the future and the problem of pancreatic drainage cannot be solved.
Double bypass surgery: biliary-intestinal + gastrointestinal anastomosis, suitable for patients with duodenal obstruction. The advantage is that duodenal obstruction can be relieved; the disadvantage is that pancreatic fluid is missing, digestive function is reduced, and endocrine function is affected.
Triple bypass surgery: biliary-intestinal + gastrointestinal + pancreatic-intestinal anastomosis. The advantage is that the pancreatic fluid problem is solved; the disadvantage is that the operation is relatively complex and difficult, and the problem of postoperative pancreatic fistula exists.
External drainage surgery.
Cholecystostomy or T-tube drainage of the common bile duct: in use in patients with unresectable tumors, the operation is simple and the drainage effect is exact. In addition to improving liver and kidney function, improving coagulation, reducing the chance of infection and improving immunity, it can also be used in the preparation before radical surgery to initially explore the tumor intraoperatively and to clarify whether a second-stage radical surgery can be performed.
Endoscopic nasobiliary duct or internal stent drainage (ERCP+ENBD): The advantage is that it is less invasive; the disadvantage is that the postoperative peribiliary edema is serious, which makes the second-stage surgery more difficult and may cause tumor metastasis due to the repeated passage of the guidewire, catheter or stent through the tumor site during the operation.
PTCD or ITCD: generally used for patients with poor general condition, unable to tolerate surgery or unable to perform ERCP, and the drainage effect is not exact.
2.Chemotherapy.
Intravenous chemotherapy: commonly used chemotherapeutic drugs include 5-Fu, mitomycin, cisplatin, etc. In recent years, Jianze has been used as the first-line drug for pancreatic cancer and has achieved better efficacy than previous drugs, but the overall effect of intravenous chemotherapy is not ideal, whether it is single drug or combined drug.
Interventional chemotherapy: it can increase the therapeutic concentration of local drugs and reduce the systemic toxic effects of chemotherapy drugs. Meanwhile, according to years of clinical practice, we found that interventional chemotherapy can not only improve the postoperative adjuvant treatment effect of pancreatic cancer, but also improve the surgical resection rate of large pancreatic cancer and prolong the survival of patients when applied preoperatively, which is the preferred adjuvant treatment method.
3.Radiotherapy: It can be used before or after surgery, especially for unresectable pancreatic body tail cancer, which can relieve intractable pain after irradiation.
4.Immunotherapy: The development of tumor is accompanied by low immune function, and pancreatic cancer is no exception. Therefore, improving patients’ immunity is also an important part of treatment of pancreatic cancer, and immunotherapy can increase patients’ anti-cancer ability and prolong survival. The commonly used drugs are: thymidine, IL-2, high polyglucagon, interferon and tumor necrosis factor, etc.
5.Gene therapy: Gene therapy is the research direction of tumor treatment, which is still in the experimental stage.
Other treatments: Traditional Chinese medicine, heat therapy and endocrine therapy can be applied in the treatment of pancreatic cancer, but the efficacy is not exact, and they are generally used in advanced tumors or as an auxiliary measure of radiotherapy.