Thursday, October 6, 2011

How Is Pancreatic Cancer Diagnosed?

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Signs and symptoms of pancreatic cancer


Jaundice is a yellowing of the skin and eyes. It occurs in at least half of all people with pancreatic cancer and in all cases of ampullary cancer.

Jaundice is caused by the accumulation of bilirubin in the body. Bilirubin is a dark yellow-brown substance that is made in the liver. Normally, the liver excretes bilirubin into bile. Bile through the bile duct into the intestine, possibly leaving the body in the stool. When the bile duct is blocked, bile can not reach the intestines, and the bilirubin accumulates.

Tumors that start with the head of the pancreas near the common bile duct. These tumors can be packed into the channel while they are still quite small. This can lead to jaundice, which may allow these tumors are at an early stage. But cancers that start with the body or tail of the pancreas do not compress the channel until they have spread through the pancreas. So far, the cancer may spread to the pancreas.

Sometimes the first sign of jaundice, darkening of bilirubin in the urine. As bilirubin in the blood increases, urine becomes brown.

If the bile duct is blocked, bile (and bilirubin) can not get through the intestines. When this happens, a person can detect the stool becomes lighter.

When bilirubin accumulates in the skin turns yellow and begins to itch.

Cancer is the most common cause of jaundice. Other causes, such as gallstones, hepatitis and other liver diseases, are much more common.

Abdominal pain or back pain

Pain in the abdomen or back is common in advanced pancreatic cancer. Cancers in the body or tail of the pancreas can grow enough and begins packing on nearby organs, causing pain. The cancer can also spread to the nerves surrounding the pancreas, which often causes back pain. The pain may be constant or may come and go. Of course, pancreatic cancer is a common cause of abdominal pain or back pain. It is most often caused by a noncancerous condition, or even another type of cancer.

Weight loss and poor appetite

Unintentional weight loss or unexpected is common in patients with pancreatic cancer. These people also complain of an appetite very tired, and little or nothing.

Gastrointestinal Problems

If the tumor to prevent the release of pancreatic juice in the intestine, a person may not be able to digest fatty foods. Undigested fat can cause the stools are unusually bright, big, fat, and they float in the toilet. The cancer may also wrap around the back of the stomach and prevent it. This can cause nausea, vomiting and pain that tends to be worse after eating.

The enlargement of the gallbladder

If the cancer blocks the bile duct, bile may accumulate in the gallbladder, which is then expanded. This can sometimes be felt by a doctor for a physical examination. It can also be detected by imaging.

Blood clots or abnormalities of adipose tissue

Sometimes the first indication that there is a cancer of the pancreas is developing a blood clot in a large vein, often a vein in the leg. This is known as deep vein thrombosis or DVT. Sometimes a clot breaks off and travels to the lungs, making it difficult to get enough air. A blood clot in the lungs is called pulmonary embolism or PE. However, having a blood clot that usually means you have cancer. Most clots are caused by other things.

Another indication that there may be a pancreatic cancer is the development of the bumpy texture of the tissues under the skin. This is caused by the release of pancreatic enzymes that digest fat.


In rare cases, cancer of the exocrine pancreas, causing diabetes (blood sugar) because they destroy the insulin-producing cells. More often, there are problems with sugar metabolism of light that no symptoms of diabetes, but can still be recognized by blood tests.

Signs and symptoms of endocrine tumors of the pancreas

Most of the signs and symptoms of pancreatic endocrine tumors (NET) are caused by excess hormones that tumors release into the bloodstream.


These tumors are gastrin, a hormone that tells your stomach to make more acid. Too much gastrin causes a condition called Zollinger-Ellison. Gastrin excess leads to the stomach to make too much acid. This leads to ulcers that can cause pain, nausea and decreased appetite. If the injury is serious, it can start to bleed. If the bleeding is light, it can lead to anemia (low red blood cell count). If bleeding is severe, it can be fatal. The excess acid may also be released in the small intestine, where it can damage the cells lining the intestine and digestive enzyme breaks down before they have a chance to digest food. This can lead to diarrhea and weight loss. Injuries in patients with gastrinomas can be difficult to treat, requiring high doses of anti-ulcer healing. Patients need to stay on these drugs for a long time, because the wounds tend to return if treatment is stopped. Most gastrinomas are cancerous.


These tumors produce glucagon, a hormone that raises levels of glucose in the blood. Excessive glucagon may cause increased blood sugar, which sometimes leads to diabetes. Patients also have problems with diarrhea, weight loss and malnutrition. Nutrition problems can lead to symptoms such as irritation of the tongue and corners of the mouth (these are known as angular cheilitis, glossitis and, respectively). Most of these symptoms are mild and usually is caused by something else. The symptom that brings most people glucagonomas with your doctor is a red rash that causes inflammation and blisters. This rash can travel from one place to another on the skin. Necrolytic migratory erythema is called and is the most distinctive feature of a glucagonoma. Most of these tumors are cancer.


These tumors produce insulin, which lowers blood sugar. Too much insulin results in blood sugar (hypoglycemia) with symptoms such as weakness, confusion, sweating and palpitations. When blood sugar is very low, it can lead to fainting or even move the patient into a coma and convulsions have. The symptoms of an insulinoma if the patient receives more sugar - either by mouth (food) or by injection into a vein (IV). Most insulinomas are benign (not cancerous).


These tumors to somatostatin, which helps regulate other hormones. The symptoms of this cancer are diarrhea, diabetes and gall bladder problems. Gallbladder problems can cause abdominal pain, nausea, loss of appetite and jaundice (yellowing of the skin). Since somatostatinoma symptoms are generally mild and are often due to among other things, these tumors are usually diagnosed at an advanced stage. Most tumors are somatastatinomas. Often, they are not before they spread to the liver, where they cause problems such as jaundice and pain.


These tumors produce a substance called vasoactive intestinal peptide (VIP). VIP can also lead to problems with diarrhea and low blood potassium levels. Patients have low levels of stomach acid, leading to problems with digestion of food. They may also have high levels of glucose in the blood. The diarrhea may be mild at first, but gets worse with time. By the time of diagnosis, most patients with severe, watery diarrhea, with no less than 20 stools a day. Most cancers are VIPomas.


These tumors are pancreatic polypeptide, which helps regulate both exocrine and endocrine pancreas. Most cancers are MEPP, and cause problems such as abdominal pain and enlarged liver. Some patients also have watery diarrhea.

Nonfunctioning tumors

These tumors are not hormone, so they do not cause symptoms in its early stages. Most of them are cancerous and begin to cause problems when they grow or spread of the pancreas. When they spread, they often spread to the liver. This can cause the liver to enlarge, which can cause pain and loss of appetite. It can also affect liver function, sometimes leading to jaundice (yellowing of the skin) and abnormal laboratory tests.

Tests to diagnose pancreatic cancer

History and physical examination

A complete medical history taken for possible risk factors for pancreatic cancer, and receive information about pain (how long was present, its severity, its location, and what makes it better or worse), loss of appetite, weight loss, fatigue and other symptoms.

A thorough physical examination, focusing particularly on the abdomen to check for any masses or fluid accumulation. Skin and whites of the eyes are checked jaundice (yellow color). Tumors, which prevent bile duct can also cause a dilated gallbladder, which can sometimes be felt on physical examination. Pancreatic cancer has spread to the liver, leading to enlarge.

Cancer can also spread to the lymph nodes above the collarbone, and elsewhere. These areas will be studied carefully for swelling that might indicate the spread of cancer.


Computed Tomography (CT, CT)

CT is an X-ray procedure that produces detailed cross-sectional images of the body. Instead of taking a photo like a standard X-ray scanner takes many pictures as it rotates around. A computer then combines these images into images that resemble sections of the body part being studied.

Before the photos were taken, could be asked to drink 1-2 pints and fluid called oral contrast. This helps outline the intestine so that some areas are mixed tumors. You can also get IV (intravenous) line through which a variety of injected dye (IV contrast). This helps better outline structures in your body.

The injection may cause some flushing (redness and warm feeling that can last for hours to days). Some people are allergic to the dye and urticaria. In rare cases, more serious reactions like trouble breathing and low blood pressure occur. Medications can be given to prevention and treatment of allergic reactions. Be sure to tell your doctor if you have had a reaction to contrast material used for x-rays.

CT scans take longer than X-rays You must lie still on a table while they are underway. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You may feel a bit limited by the ring you have to live when the pictures are taken.

CT scans are often used to diagnose pancreatic cancer and are useful in organizing the cancer (determining the extent of its spread). CT scans are very clear that the pancreas and can often confirm the location of the cancer. The CT can also show the organs near the pancreas and lymph nodes and distant organs where the cancer has spread. The scanner can help determine whether surgery is a good treatment option.

CT can also be used to guide the needle biopsy accurately in the area suspected of spreading. This procedure is called CT-guided biopsy, the patient remains TAC table radiologist advances a biopsy needle to the location of the mass. CT is repeated until the doctors are confident that the needle is within the mass. A biopsy sample is then removed and looked at under a microscope.

Magnetic resonance imaging (MRI)

MRI uses radio waves and strong magnets instead of x-rays. The radio wave energy is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern of a detailed image of parts of the body. This product not only of the transverse slices of the body, such as a scanner that can also produce slices that are parallel to the length of the body. A contrast can be injected just as with CT, but it is less common.

Most doctors prefer CT to see the pancreas, but an MRI can sometimes provide additional information. MRI scans are particularly useful to examine the brain and spinal cord.

MRI is a bit more uncomfortable than CT scans. They take longer - often up to an hour. You may have to be within a narrow tube, which is binding and can upset people with fear of enclosed spaces. The new "open" and can help with this, if necessary. The MRI scanner makes noises that can be uncomfortable. Some places provide headphones with music to block this.

Scintigraphy of somatostatin receptors

Somatostatin receptor scintigraphy (SRS), also known as OctreoScan, can be very useful for the diagnosis of pancreatic neuroendocrine tumors. It uses a hormone like substance called octreotide, which is linked to the radioactive indium-111. Octreotide attaches to proteins in cancer cells of many networks. A small amount of this substance into a vein. It works in the blood, and has attracted neuroendocrine tumors. Approximately 4 hours after injection, a special camera can be used to show where the radioactivity is accumulated in the body. Additional scans can be done in a few days. NET when you come to scan the SRS, can mean that the tumor stops growing when treated with octreotide.

Positron emission tomography (PET)

PET with intravenous glucose (sugar), which contains a radioactive atom into the blood. Cancer cells grow rapidly in the body to absorb more radioactive glucose than normal cells. A special camera can then create a picture of areas of radioactivity in the body. Not finely detailed images such as CT or MRI, but provides useful information. This test is useful to look for spread of pancreatic cancer, but the networks grow slowly, do not appear well-PET.

Combined PET / CT and a PET scan to identify better the tumor. This test can be particularly useful for identifying exocrine cancer that has spread beyond the pancreas and can not be treated with surgery. It can be a useful test for cancer staging. It may even be able to detect early cancers.

Ultrasound (ultrasonography or U.S.)

Ultrasound uses sound waves to produce images of internal organs like the pancreas. For an abdominal ultrasound, a wand-shaped probe called a transducer is placed on the skin of the abdomen. That emits sound waves and detects the echoes that bounce off internal organs. The pattern of echoes is processed by a computer to produce an image on a screen.

The echoes made by most pancreatic tumors differ from normal pancreatic tissue. Different patterns of echoes can help distinguish some types of pancreatic tumors in the other.

If the symptoms suggest that pancreatic cancer is likely that CT is often more useful than ultrasound accurate diagnosis. But if it is not clear whether any other disease could explain the symptoms of the patient, the ultrasound can be done.

Endoscopic ultrasound is more accurate than abdominal ultrasonography and is probably the best way to diagnose pancreatic cancer. This test is performed with an ultrasound probe attached to an endoscope - a thin, flexible tube optical fiber used by doctors to see inside the bowel. Patients are sedated first (medication given to them sleepy). The tube is passed through the mouth or nose into the esophagus (the tube that connects the mouth to the stomach) and stomach, and the first part of the small intestine. The probe can be directed to the pancreas, which lies next to the small intestine. The probe is located at the tip of the endoscope, then you can be near the area where the tumor to take pictures. This is a great way to see the pancreas. It is better than CT for detecting small tumors. If the tumor is, you can take a biopsy during this procedure.

Endoscopic cholangiopancreatography forth (ERCP)

This procedure endoscope (a thin, lighted, flexible tube) is passed through the patient's throat into the esophagus and stomach, and the first part of the small intestine. The doctor can see through the endoscope and find Vater (the common bile duct is connected to the small intestine). The doctor guides a catheter (small tube) at the end of the endoscope into the common bile duct. A small amount of dye (contrast medium) is injected through a tube in the common bile duct and x-ray pictures are taken. This dye helps outline the bile duct and pancreatic duct. X-rays can show narrowing or blockage of these channels, which can cause pancreatic cancer. The doctor does this test can also put a small brush through the tube to remove cells from a biopsy (to see under a microscope to see if they appear as cancer). This procedure is usually done while the patient is sedated (given medicines so that they are sleeping).

ERCP can also be used to place a stent (small tube) into bile duct to keep it open if a tumor is close to tapping it. This is described in more detail in the section on palliative surgery in "Surgery" section.


This is an x-ray procedure to look at blood vessels. A small amount of contrast material is injected into an artery to describe the blood vessels. After that, X-rays taken.

Angiography can show whether the blood flow in a certain area is blocked or compressed by a tumor. It can also show abnormal blood vessels (power of cancer) in the region. This test may be useful to find out if a pancreatic cancer may have grown through the walls of some blood vessels. Primarily, it allows surgeons to determine if the cancer can be completely removed without damaging vital blood vessels and helps to plan the operation.

Angiography can also be used to search for pancreatic endocrine tumors that are too small to be seen on imaging studies. These tumors cause the body to make more blood vessels to "feed" the tumor. These extra blood vessels can be seen on angiography.

Angiography can be an uncomfortable procedure because the radiologist who performs it is to put a small catheter into the artery supplying the pancreas. Usually the catheter is placed in an artery in the inner thigh and threaded up to the pancreas. Local anesthesia is often used to numb the area before inserting the catheter. Then the dye is injected quickly to describe all the ships, while X-rays are taken.

Blood tests

Several blood tests can be used to help diagnose cancer of the pancreas or to help determine treatment options if it is.

Blood tests that look at the different levels of bilirubin (a chemical produced by the liver) are useful in jaundice due to liver disease or obstruction of the patient (by gallstones, tumors or other diseases), the flow of bile .

High blood levels of tumor markers CA 19-9 and carcinoembryonic antigen (CEA) may point to a diagnosis of exocrine pancreatic cancer, but these tests are not always accurate (see "Can pancreatic cancer is the beginning? ").

Other blood tests can help assess a patient's general health status (such as the liver, kidneys and bone marrow). These tests can also help determine whether they will be able to withstand the stress of major surgery.

Pancreatic neuroendocrine tumors

Blood tests to look at the level of some pancreatic hormones may help diagnose pancreatic neuroendocrine tumors (NET). For insulinomas, insulin, glucose, and C-peptide levels are measured when the patient is fasting (not eating or drinking). (C-peptide is a byproduct of insulin production). Blood is drawn every 6 to 8 hours until the patient begins to experience symptoms. The diagnosis of insulinoma is made when there is sugar in the blood with high levels of insulin and C-peptide. Other pancreatic hormones such as gastrin, glucagon, somatostatin, pancreatic polypeptide and VIP can be measured in blood samples, and can be used to diagnose pancreatic NET. Measuring levels of a substance called chromogranin A (CGA) can be very useful. This level rises in most cases of pancreatic cancer NET - even non-functioning tumors.

Increased levels of gastrin in patients taking the drug class known as anti-ulcer inhibitors proton pump. Examples of these drugs include omeprazole (Prilosec ®), esomeprazole (Nexium ®), lansoprazole (Prevacid ®), and others. These drugs are commonly used to treat people with stomach pain and heartburn. The patient must be out of the inhibitors of proton pump at least one week before a gastrin level is obtained so that the medicine is not wrong to raise the level of gastrin. Gastrin levels are most useful when combined with a test that measures the amount of acid in the stomach. This is because low levels of acid can lead to high levels of gastrin. When a gastrinoma is present, high gastrin levels are perceived as the acid levels.


The story of an examination of the patient, physician and results of imaging tests can be highly indicative of pancreatic cancer, but the only way to be sure is to take a small sample of the tumor and look under the microscope. This is called a biopsy.

There are several types of biopsies. This procedure is most often used to diagnose cancer of the pancreas is called fine needle aspiration (BTI), a biopsy. In this experiment, a doctor adds a thin needle through the skin and pancreas. The doctor uses CT scan or endoscopic ultrasound to examine the state of the needle and make sure it is a tumor.

Doctors can also biopsy of the tumor using endoscopic ultrasound to place the needle directly through the wall of the duodenum in the tumor. In both cases, tissue samples are removed by small needle. The main advantages of this test is that the patient does not require general anesthesia (no "sleep") during the test, and the major side effects are rare.

In previous biopsies, surgical, were performed more frequently. This type of biopsy involves a laparotomy (large incision through the skin in the abdominal wall to examine the internal organs). Areas to look or feel abnormal can be sampled by removing a small piece of tissue with a scalpel or a needle. The surgeon may use a fine needle (as in a biopsy). Most commonly, surgeons use a larger needle removes a cylindrical core of tissue about 1 / 2 inch long and an inch less than 1 / 8 inch in diameter (called a biopsy). The main disadvantage of this type of biopsy is that the patient must undergo general anesthesia and remain in the hospital for a period of time to recover.

Laparotomy is now rarely recommended. The doctors prefer to use laparoscopy (sometimes called keyhole surgery) as a way of looking at and maybe take a piece of the pancreas with a biopsy. Patients are usually sedated for this procedure. The surgeon makes several small incisions in the abdomen and add a small telescope like instruments in the abdomen. One of these is usually connected to a video monitor. The surgeon can look at the belly and how big it is and if cancer has spread, and may take a tissue sample as well.

Most doctors who treat pancreatic cancer try to avoid surgery unless imaging tests suggest that the operation might be able to remove all visible cancer. Even after the imaging and laparoscopy, there are times when the surgeon begins the operation intended to remove the cancer, but finding during surgery has spread too far from being eliminated. In these cases, a tumor sample is taken only to confirm the diagnosis, and the rest of the proposed transaction is stopped.


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