A considerable number of patients diagnosed with pancreatic cancer are simultaneously diagnosed with diabetes mellitus and nearly half of them exhibit decreased glucose tolerance [20] [21]; the inverse observation is not valid, however, in the sense that diabetes precedes pancreatic cancer almost always [22].

PA is a disease that is known to cause no symptomatology until it's advanced stages, which accounts for its high mortality and therapeutic failure. The symptoms it induces are also fairly non-specific and include:

• Abdominal pain, frequently located in the coastal margin of the left upper abdominal quadrant.
• Osphyalgia
• Weight loss
• Cachexia or malnutrition
• Jaundice
• Anorexia
• Episodes of pancreatitis
• Nausea
• Emesis

• Weight Loss

  GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. [ncbi.nlm.nih.gov]

  Symptoms can include a lump in the tummy, tummy pain, weight loss and sickness. Pancreatoblastoma This rare type of pancreatic cancer mostly affects children. It is extremely rare in adults. [pancreaticcancer.org.uk]

• Ascites

  EUS showed ascites in 27 (20%) patients, of whom 8 (29.6%) had PC. The sensitivity, specificity, PPV, NPV and accuracy of ascites by EUS in the detection of PC in this group of patients were 67%, 85%, 30%, 96% and 83%, respectively. [ncbi.nlm.nih.gov]

  Ascites : Abdominal fluid buildup often caused by cirrhosis. Ascites may cause the abdomen to protrude impressively. Abdominal hernia : A weakening or gap in the abdominal fascia allows a section of the intestine to protrude. [webmd.com]

  She was also noted to have fatty infiltration of the liver (although not overt cirrhosis) and ascites. She was then referred for further evaluation. [liebertpub.com]

  Imaging The initial imaging for pancreatic cancer is commonly an abdominal ultrasound, which may demonstrate a pancreatic mass or a dilated biliary tree (as well as potential hepatic metastases and ascites if very late stage disease). [teachmesurgery.com]

• Painless Jaundice

  This patient initially presented with painless jaundice and computed tomography (CT) revealed a mass in the head of the pancreas. Brushings obtained at endoscopic retrograde cholangiopancreatography (ERCP) were positive for adenocarcinoma. [ncbi.nlm.nih.gov]

  […] multiple mole melanoma (FAMMM) hereditary pancreatitis ataxia-telangiectasia Peutz-Jeghers syndrome Perhaps surprisingly there is only a weak if at all present association with heavy alcohol consumption 1. pain (most common) Courvoisier gallbladder: painless [radiopaedia.org]

  jaundice The majority of pancreatic cancer is incurable at presentation 1 2 Whether or not pancreatic cancer is deemed curable, current surgical, endoscopic, and oncological management regimes can significantly improve quality of life Trials are currently [bmj.com]

  Another symptom is painless jaundice (yellowish discoloration of the eyes) associated with passage of tea-colored urine and grayish-white (acholic) stools when immediately noticed are early signs. [iorbitnews.com]

• Malnutrition

  Six patients suffered from significant morbidities including recurrent cholangitis, second malignancy, malnutrition and bowel perforation. A rare subset of patients with pancreatic cancer achieve long-term survival without resection. [ncbi.nlm.nih.gov]

  Patients should be hospitalized and treated for biliary or duodenal obstruction, acute cholangitis, severe pain, neutropenia and fever, and malnutrition. [cancertherapyadvisor.com]

  A patient affected by pancreatic cancer may report non-specific symptoms such as weight loss, anorexia, malnutrition, pain in the right upper side of the abdomen, back pain and jaundice. [symptoma.com]

  Malignant gastric outlet obstruction refers to tumor blockage of the outlet of the stomach, prohibiting the passage of food from the stomach into the small intestine, and causes severe nausea and vomiting, in addition to malnutrition. [pancreapedia.org]

• Fever

  One year after the second procedure, the patient enjoys good health and has been free of fever and abdominal pain and has not received any antibiotic therapy. [ncbi.nlm.nih.gov]

  Side effects of chemotherapy for patients who receive it include neutropenia and fever. (See Table II.) Table II. [cancertherapyadvisor.com]

  Side effects of chemotherapy for patients who receive it include neutropenia and fever. (See Table II. ) Table II. [clinicaladvisor.com]

  […] and whites of the eyes (jaundice) – it also may cause dark yellow or orange pee, pale-coloured poo and itchy skin Other possible symptoms of pancreatic cancer include: feeling sick and being sick changes in bowel movements (diarrhoea or constipation) fever [nhs.uk]

• Nausea

  A 63-year-old woman presented to the hospital with persistent nausea, dyspepsia and weight loss for 6 months. Abdomen CT showed a low-attenuation mass, approximately 7.6 cm diameter, in the region of the body and tail of the pancreas. [ncbi.nlm.nih.gov]

  Symptoms can include tummy pain, weight loss, and feeling and being sick (nausea and vomiting). Solid pseudopapillary neoplasm Solid pseudopapillary neoplasms grow mostly in the body and tail of the pancreas. They are more common in younger women. [pancreaticcancer.org.uk]

• Abdominal Pain

  GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. [ncbi.nlm.nih.gov]

  The main symptoms include fatigue, weight loss, abdominal pain, and jaundice. [symptoma.com]

• Loss of Appetite

  They include: loss of appetite unintentional weight loss abdominal (stomach) or lower back pain blood clots jaundice (yellow skin and eyes) depression Pancreatic cancer that spreads may worsen preexisting symptoms. [healthline.com]

  Call for an appointment with your provider if you have: Abdominal or back pain that does not go away Persistent loss of appetite Unexplained fatigue or weight loss Other symptoms of this disorder Preventive measures include: If you smoke, now is the time [nlm.nih.gov]

  The side effects include: mild skin changes resembling sunburn or suntan nausea, vomiting, and diarrhea fatigue loss of appetite weight loss Most side effects subside a few weeks after completing treatment. [medicalnewstoday.com]

• Abdominal Mass

  Diagnosis of cystadenocarcinoma is made by abdominal CT or MRI, which typically shows a cystic mass containing debris; the mass may be misinterpreted as necrotic adenocarcinoma or pancreatic pseudocyst. [msdmanuals.com]

  Sometimes they present as an abdominal mass found on examination. [pancare.org.au]

  Imaging The initial imaging for pancreatic cancer is commonly an abdominal ultrasound, which may demonstrate a pancreatic mass or a dilated biliary tree (as well as potential hepatic metastases and ascites if very late stage disease). [teachmesurgery.com]

  Physical findings included upper abdominal tenderness in 4 patients, jaundice in 2 patients with tumors in the head of the pancreas, and a palpable abdominal mass in 1 patient. [jamanetwork.com]

  […] problems ( ascites, abdominal mass) Depression Venous thrombosis Palpable lymph nodes (cervical, clavicular) The symptoms of pancreatic cancer are generally vague and can easily be attributed to other less serious and more common conditions. [emedicinehealth.com]

• Epigastric Pain

  CASE REPORT: A 38-year-old man with a synchronous 6-month history of thyroid swelling, presented with epigastric pain and signs of obstructive jaundice. [ncbi.nlm.nih.gov]

  Common presenting symptoms include epigastric pain that radiates to the back, unexplained weight loss, painless jaundice, light clay-colored stools, dark urine, pruritus, nausea, and 10% develop spontaneously appearing and disappearing thromboses. 7, [nature.com]

  Some common presenting symptoms include epigastric pain radiating to the back, weight loss, jaundice and/or light colored stools (more typically for tumors in the head of the pancreas), digestive problems, anorexia, nausea, pancreatitis-related symptoms [atlasgeneticsoncology.org]

• Jaundice

  Malignant biliary obstruction occurs as a result of tumor compression of the common bile duct, leading to severe jaundice. [pancreapedia.org]

  This patient initially presented with painless jaundice and computed tomography (CT) revealed a mass in the head of the pancreas. Brushings obtained at endoscopic retrograde cholangiopancreatography (ERCP) were positive for adenocarcinoma. [ncbi.nlm.nih.gov]

  키워드, , Primary pancreatic lymphoma, Obstructive jaundice, Acute pancreatitis [kci.go.kr]

• Hepatomegaly

  Suspicion of pancreatic cancer → take a detailed history and perform physical exam, evaluating especially for abdominal distention (ascites), a palpable gallbladder, hepatomegaly, and enlarged supraclavicular lymph node(s) → draw serum lab work → proceed [cancertherapyadvisor.com]

  Hepatomegaly is seen in 65% of patients and may indicate liver metastasis, although the sign is nonspecific. [slideplayer.com]

  Patients presenting with or developing advanced intra-abdominal disease may have ascites, a palpable abdominal mass, hepatomegaly from liver metastases, or splenomegaly from portal vein obstruction. [emedicine.medscape.com]

• Liver Mass

  Axial venous-phase contrast-enhanced MDCT image shows hypodense mass (arrow) in pancreatic head. Note homogeneous liver enhancement, without evidence of metastases. [ajronline.org]

  She has a small (2cm) mass on the head of her pancreas and liver masses on her enlarged liver. She bloated, NO JAUNDICE, constipation every 3 days, vomiting whenever she’s constipated. [netrf.org]

• Gallbladder Enlargement

  Assessing symptoms The physician will pay special attention to common symptoms such as: abdominal or back pain weight loss poor appetite tiredness irritability digestive problems gallbladder enlargement blood clots, deep venous thrombosis (DVT), or pulmonary [medicalnewstoday.com]

• Back Pain

  Abdominal pain and back pain were the presenting symptoms in 75% and 33.3% of patients respectively. Pancreatic adecnocarcinoma is a rare cancer in pregnancy. A high index of suspicion is required in case of atypical symptoms. [ncbi.nlm.nih.gov]

  Symptoms can include tummy (abdominal) and back pain, weight loss and changes to bowel habits. Read more about the symptoms of PDAC. Rare exocrine cancers One in a hundred pancreatic cancers (1%) are rare exocrine cancers. [pancreaticcancer.org.uk]

  Unexplained weight loss, abdominal pain, nausea, vomiting. Back pain is another one, because the pancreas is very posterior in the body. [scientificamerican.com]

  pain, dyspepsia, and unexplained weight loss, as well as the classic presentation of painless jaundice The majority of pancreatic cancer is incurable at presentation 1 2 Whether or not pancreatic cancer is deemed curable, current surgical, endoscopic [bmj.com]

• Mid Back Pain

  Mid-back pain or discomfort Where a bra strap would sit and may be eased by leaning forward. Indigestion Not responding to medication. Pale and smelly stools That don’t flush easily. [pancreaticcanceraction.org]

• Pruritus

  Adenocarcinomas of the head of the pancreas cause obstructive jaundice (which can cause pruritus) in 80 to 90% of patients. [msdmanuals.com]

  Generalized pruritus or pangangati ng katawan without wheal formation may develop with jaundice. Sometimes, despite absence of a strong family history of Diabetes, many of these patients with Pancreas Cancer may have elevated levels of blood sugar. [iorbitnews.com]

  Urine darkening, stool changes, and pruritus are often noticed by patients before clinical jaundice. Pruritus may accompany and often precedes clinical obstructive jaundice. Pruritus can often be the patient's most distressing symptom. [emedicine.medscape.com]

  Side effects of morphine and fentanyl include nausea, vomiting, constipation, pruritus, sedation, confusion, lethargy, respiratory depression, miosis, hypotension, biliary spasm, and bradycardia. [cancertherapyadvisor.com]

  Because more than two-thirds of adenocarcinomas occur in the head of the pancreas, abdominal pain, jaundice, pruritus, dark urine, and acholic stools may be presenting symptoms. [aafp.org]

• Peripheral Neuropathy

  […] advanced pancreatic cancer.[4] Recently, the gemcitabine plus nab-paclitaxel combination was shown to increase median survival by 1.8 months, with increased overall survival at 1 and 2 years; adverse effects were reasonable and included cytopenias and peripheral [cancernetwork.com]

  The main adverse effects are peripheral neuropathy, neutropenia, thrombocytopenia and fatigue. These promising results need to be confirmed in a comparative randomised trial. [nature.com]

  Of patients with grade 3 peripheral neuropathy, 44% were able to resume treatment at a reduced dose within a median of 23 days after onset of a grade 3 event. [cancer.gov]

• Dark Urine

  Early signs of pancreatic cancer include: pain in the upper abdomen loss of appetite nausea and vomiting weight loss changed bowel motions - either diarrhoea or severe constipation jaundice (yellowish skin and eyes, and dark urine). [cancer.org.au]

  Symptoms of pancreatic cancer include: Diarrhea Dark urine and clay-colored stools Fatigue and weakness Sudden increase in blood sugar level (diabetes) Jaundice (a yellow color in the skin, mucous membranes, or white part of the eyes) and itching of the [nlm.nih.gov]

  Because more than two-thirds of adenocarcinomas occur in the head of the pancreas, abdominal pain, jaundice, pruritus, dark urine, and acholic stools may be presenting symptoms. [aafp.org]

  One or more of the symptoms below may be present: Jaundice (yellowing of the skin and the whites of the eyes, dark urine) Pain in the upper abdomen and/or upper back Loss of appetite Unexplained weight-loss Weakness Diarrhea or constipation Nausea and [bccancer.bc.ca]

The evolution of imaging modality technology has positively affected the success rates in the diagnosis of pancreatic cancer during the past years. A computerized tomography scan (CT) or a magnetic resonance imaging scan (MRI) can both be used to diagnose pancreatic cancer and stage the disease, which is a useful tool for the surgeon to develop a proper therapeutic strategy. Other modalities that can be employed include the multi-detector computed tomography (MDCT) and the endoscopic ultrasound (EUS). The latter also allows for tissue sampling, which provides the material for a histological analysis, the gold standard for a definitive diagnosis. A positron emission tomography (PET) scan can also provide useful information under some circumstances [23].

Staging of the disease requires the detection of metastatic disease, the possible locations of metastasis can be identified via the performance of a contrast-enhanced thin slice CT scan [24] [25].

• Pancreatic Calcification

  Differential diagnoses Disease Characteristics Notes Chronic pancreatitis Classic triad of pancreatic calcification, steatorrhea, and diabetes mellitus is observed in one-third of patients. Abdominal pain and weight loss are frequently present. [clinicaladvisor.com]

  Are pancreatic calcifications specific for the diagnosis of chronic pancreatitis? A multidetector-row CT analysis. Clin Radiol. 2009; 64 :903–911. [ PubMed ] 70. Kajiwara M, Kojima M, Konishi M, et al. [ncbi.nlm.nih.gov]

• Hypoglycemia

  There are different kinds, including: Insulinomas produce large amounts of the hormone insulin which can result in hypoglycemia ( low blood sugar). [pathology.jhu.edu]

• Hyperglycemia

  Is hyperglycemia a prognostic factor in pancreatic cancer? [abstract] J Clin Oncol. 2006; 24 Suppl 1 Abstract 14076. 13. Chari ST, Leibson CL, Rabe KG, et al. Probability of pancreatic cancer following diabetes: a population-based study. [ncbi.nlm.nih.gov]

Depending on the cancerous progression, different therapeutic interventions can be performed. Accurate staging is required prior to the initiation of any therapeutic regime.

In general, patients with a tumor that is believed to be operable may proceed to a pancreatectomy with or without prior chemotherapy. The administration of chemotherapy is greatly affected by the accuracy of the staging process prior to surgery [25] [26]. Studies have shown that the best prognosis is reserved for those patients who receive neoadjuvant chemotherapy, followed by excision of the malignant tumor [27]. Chemotherapy also contributes to better surgical results if the patient will also need vein resection [28].

On the other hand, progressed disease is always initially treated with the administration of chemotherapy. Patients who are diagnosed with the metastatic disease are faced with an extremely poor prognosis, as the average survival rate ranges between 3 to 6 months. However, tumors that have locally expanded can be downstaged with the administration of chemotherapy to a size that is deemed operable; the prognosis for these patients does not differ from that of the patients who were initially considered good candidates for excision without neoadjuvant chemotherapy [29]. The agents commonly used are Fluorouracil or Gemcitabine.

Pancreatic adenocarcinoma is usually diagnosed at an advanced stage, since in the early stages of the disease, no symptoms are usually produced. Following a pancreaticoduodenectomy, the associated mortality rate is low, approximately 2%, and greatly depends on the experience of the surgeon and the facilities it is carried out in [17] [18]. Even after a successful pancreaticoduodenectomy, complications are frequently reported, including wound infection, delayed gastric emptying, fistulas, cardiac pathologies, abscesses and cholangitis [17].

In general, a surgical intervention aimed at the excision of the pancreatic tumor is followed by a 5-year survival rate of maximum 25%. Prognosis is adversely affected by excessive tumor expansion, poor differentiation and infiltrated lymph nodes. Mutations of the SMAD4 gene are also linked to a higher risk of metastatic disease, even after surgical excision [19].

Pancreatic adenocarcinoma is characterized by an etiological analysis that has yet to be clearly defined. A certain genetic background has been proposed, given that a 10% of the patients affected by it also have a family history of pancreatic malignancy [3] [4]. Genes such as BRCA2, STK11, PALB2, and p16/CDKN2 have been identified as playing a role in the pathophysiology of this malignancy, as well as other low-penetrance genes [5] [6] [7] [8] [9]. Other risk factors that have been associated with pancreatic cancer are obesity, alcohol abuse, smoking, family history of this type of cancer and diabetes mellitus.

PA is in the top five malignancies that are accompanied by the highest mortality rates in the USA [10]. A family history of pancreatic cancer does indeed increase the risk of malignancy in a first-degree relative of the affected person. In addition to familial cases of pancreatic cancer, first-degree relatives of patients who have been diagnosed with sporadic cancer surprisingly also have increased chances of suffering from the same disease [11].

Familial pancreatic cancer exhibits a poor prognosis, as it tends to lead to metastatic or synchronous malignancies in other organs and also evince a greater number of pre-neoplastic lesions [12] [13].

The pancreas is an organ situated in the upper left part of the abdomen, in the region posterior to the stomach. The duality of its function makes it a structure indispensable to the body in order to perform vital functions. It acts an exocrine gland, producing enzymes that facilitate digestion, and an endocrine gland, which partakes in the production of hormones like insulin.

The majority of pancreatic malignancies are generated at the exocrine region of the organ and nearly all of them are identified as pancreatic adenocarcinomas, a type of pancreatic cancer that is known to progress rapidly. The primary issue is that pancreatic cancer causes no symptomatology until the tumor has reached considerable dimensions and the disease is many times too advanced for any treatment option to prove successful [14].

PA is a type of tumor that evolves from primary lesions which may occur at various occasions during the condition's development. Some of these pre-cancerous lesions are:

• PanIN (Pancreatic intraepithelial neoplasia) is the lesion that precedes most pancreatic malignancies. Three stages have been established (I, II, III), characterized by a progressively greater number of atypical cells [15]
• Intraductal papillary mucinous neoplasms
• Mucinous cystic neoplasms

Genetic factors play an important role in the evolution of pancreatic number since a series of events has been found to lead to the final malignancy status. Initially, mutations occur in the K-RAS gene of the epithelial cells in the pancreas, this results in an increased cellular reproduction, with equally increased cellular survival and invasion potential. Later on, the p16 tumor suppressor gene is inhibited, leading to a cellular architectural loss. The deactivation of p53 tumor suppressor gene, which ensues in 70% of the cases, influences apoptosis and DNA repairment procedures and both processes are hindered. The final deviation from the normal genetic pattern includes the deactivation of the SMAD4 gene, which is detected in half of the patients affected by PA. [16]

The consumption of foods with low-calorie count has been proven to augment the risks of developing pancreatic cancer. Therefore, every individual is advised to maintain healthy eating habits and follow a diet that contains fruit, vegetables, wholegrain products, and nuts. Consumption of these products leads to lower inflammation signalling and hinders the occurrence of vascular disorders, thus reducing the risks of pancreatic malignancy.

Pancreatic cancer usually affects the exocrine region of the organ, namely the one responsible for the production of digestive enzymes. The most common type is pancreatic adenocarcinoma (PA), a subtype that rapidly progresses. Pancreatic tumors develop on the ground of other, precursor lesions, the most common being PanINs, which stands for pancreatic intraepithelial neoplasm [1].

Various risk factors have been proposed to contribute to the pathogenesis of pancreatic adenocarcinoma, such as obesity, alcohol abuse, smoking, and diabetes. Even though the exact causes and pathophysiological mechanisms that underlie the disease have not yet been accurately identified, various genetic mutations occur gradually during the course of the disease evolution; each contributes to a specific type of function disruption that ultimately leads to a cancerous tumor [2]. More specifically:

• K-RAS mutation is the first to occur. Disrupts the apoptotic process and DNA repair.
• Inactivation of tumor suppressor genes, such as TP53 and p16/CDKN2A, ensues and leads to a loss of cellular architecture.
• Inactivation of SMAD4 occurs in the final stages and in almost half of the patients.

Pancreatic adenocarcinoma is asymptomatic until a progressed stage has been reached; this accounts for the delayed diagnosis and the high mortality rates that accompany the disease, even after proper treatment has been administered. The symptoms that originate from pancreatic cancer are non-typical - fatigue, weight loss, anorexia, jaundice, abdominal pain, and osphyalgia.

PA is diagnosed with imaging modalities, such as an endoscopic ultrasound, a magnetic resonance imaging scan or a computerized tomography scan of the abdomen. Depending on the location and expansion of each tumor, patients may undergo surgical resection, chemotherapy, radiation therapy or a combination of the aforementioned options.

The pancreas is an organ that is situated in the back portion of the abdomen, behind the stomach. It is responsible both for the production of enzymes that, alongside bile, help to digest food. The pancreas is a unique organ whose function cannot be substituted.

Pancreatic cancer is a frequently diagnosed type of cancer. It is one of the top 5 causes of death due to cancer in the United States and every year, it is believed that it leads approximately 250,000 patients to death. This type of malignancy is followed by such mortality rates because the initial stages of the disease lead to no symptoms. Therefore, patients only present for a medical evaluation when the disease has progressed too far; intervention is, therefore, limited and therapeutic success rates are generally low.

Pancreatic cancer usually affects the part of the pancreas that produces digestive enzymes and most cases involve a pancreatic adenocarcinoma (PA). Although its is unknown how the disease is caused or triggered, a genetic predisposition has been established. It is known that first-degree relatives of patients affected by pancreatic cancer and have a family history of the condition have a higher risk of developing the malignancy themselves when compared to the general population. Other risk factors include excessive alcohol consumption and high-calorie intake, obesity, and diabetes. Genetic mutations that occur gradually during the development of the disease have been identified but they are not the actual causes of cancer. Each genetic mutation contributes to a certain abnormality that facilitates the evolution of cancer. Pancreatic malignant tumors develop on the grounds of other, pre-existing tumors.

A patient affected by pancreatic cancer may report non-specific symptoms such as weight loss, anorexia, malnutrition, pain in the right upper side of the abdomen, back pain and jaundice. The disease is diagnosed by a radiologic depiction of the tumors, which can be achieved with an abdominal CT or MRI scan, or an endoscopic ultrasound. When performing the latter, the physician is able to take some samples which can be biopsied, so that a definitive diagnosis can be achieved. The treatment depends on how progressed the disease is. Metastasis implies that the patient cannot be operated on; such people are expected to survive for 3 to 6 more months. On the other hand, patients who can be surgically treated have a better prognosis. Surgery involves a resection of the tumor, with or without a resection of a part of the duodenum. Chemotherapy and radiation therapy are also beneficial under some circumstances.

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