Malignant Tumors: Carcinoma, Gross Pathology and Clinical Features

Malignant Tumors: Carcinoma, Gross Pathology and Clinical Features

Carcinoma of the – pancreas is one o£ the malignant tumors which is most diffi­cult to diagnose and, therefore, usually poorly treated. About 4 per cent of all cancer deaths are due to malignant tumors of the pancreas. The most com­mon site is the head where over 40 per cent of the cancers are found. About 20 per cent are diffuse, and the remaining 40 per cent are found in the neck, body and tail. A statistically significant pre­ponderance has been found in males, in most series 2:1 or more. The average age of diagnosis is about 55 years.

Except for those lesions arising close to the ampulla or common duct, the symptoms of pancreatic carci­noma make their appearance late. The most common symptom is pain, which occurs in about 85 per cent of the cases. Weight loss occurs before the diagnosis is made in about the same percentage, and this weight loss is frequently extreme. Painless jaundice, commonly considered the symptom leading to the diagnosis of carcinoma of the pancreas, is rather sel­dom a primary sign. As a matter of fact, jaundice, with oj|without pain, appears in fewer cases before diagnosis is made than do pain and weight loss. Anorexia, present in over half of the patients and mostly associated with nausea and vomit­ing, is a probable explanation for much of the weight loss. Changes in the stools, with diarrhea or large, bulky stools con­taining much undigested fat, are fairly characteristic of those patients whose pancreatic duct is obstructed. The pain, which may be colicky or intermittent in type, is much the same as with biliary disease, including the radiation to the subcapsular areas. It may also radiate diffusely to the back, abdomen or, in paroxysms, to the chest, or it may be a dull, steady ach­ing pain in the midepigastrium boring through to the back, a pain which has been unduly stressed as being typical of pancreatic disease.

Definitive diagnosis before operation is difficult. The presence of jaundice and of a palpable mass pointing to a dilated gallbladder is strongly suggestive of carcinoma of the head of the pancreas, ampulla of Vater or common duct (Cour – voisier’s law). The liver may be enlarged in such cases of co mmon bile duct obstruction or because of tumor or metastases, but hepatomegaly does not necessarily indicate metastases and is not a sign of inoperability. The pancreatic mass itself is rarely palpable, except in very late cases. A cyst or pancreatitis may occur behind the neoplastic obstruction of the duct. X-ray diagnosis rests upon distortions of adjacent organs which can be visual­ized, concerning mostly the duodenum and occasion­ally the gallbladder, stomach or colon. Widening of the duodenal loop has been reported as the diagnostic X-ray sign for a pancreatic tumor, but it is rarely seen in operable lesions. Invasion of the wall of the duodenum or stomach may be visualized as deformi­ties, e. g., an inverted S type of duodenal deformity. Duodenal drainage, though not often applied, is of particular value for differential diagnosis. With obstruction of the pancreatic ducts, pancreatic enzymes will be absent, or present in only small amounts. Cellular cytologic studies may reveal malignant cells, especially in those lesions involving the main ducts.

Malignant Tumors

Malignant Tumors: Carcinoma, Gross Pathology and Clinical Features

Even at operation the establishment of the diag» nosis of carcinoma may not be easy in early cases. The cancer is ordinarily hard and pale and causes enlargement of the gland, but these features may also be conspicuous in chronic pancreatitis . Biopsy will frequently show only chronic pancreatitis in the surrounding tissue, which cannot be distin­guished by palpation from the tumor itself. In many instances, resection without a positive pathologic diagnosis will be justified and proved correct, especially if the pancreatic duct distal to the tumor is dilated and if the common bile duct is obstructed.

The only treatment presently available is resec – tional surgery, but this too is limited because of fre­quent extension along the pancreatic or common bile ducts, early lymphatic extension in widely separated areas and perineural spread. Despite the difficulties in diagnosis and the extensive surgery involved, 5-year cures of carcinoma of the pancreas are now being reported more frequently than in former years.

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