Pancreatic cancer
Introduction
Introduction to pancreatic cancer Pancreatic cancer (pancreatic carcinoma) is a common pancreatic tumor. It is a malignant tumor with high degree of malignancy and difficult diagnosis and treatment. About 90% of ductal adenocarcinomas originating from the glandular epithelium, its incidence and death. The rate has increased significantly in recent years. The 5-year survival rate is <1%, which is one of the worst prognosis of malignant tumors. The early diagnosis rate of pancreatic cancer is not high, the operative mortality rate is high, and the cure rate is very low. The incidence of this disease is higher in men than in women, men and women. The ratio is 1.5~2:1, male patients are much more common than premenopausal women, and the incidence of postmenopausal women is similar to that of males. basic knowledge The proportion of illness: 0.02% Susceptible people: no specific population Mode of infection: non-infectious Complications: Diabetes
Cause
Causes of pancreatic cancer
Smoking (15%):
Animal experiments have shown that feeding animals with tobacco acid water can cause pancreatic cancer. A large sample of survey results show that smokers have 1.5 times more chance of developing pancreatic cancer than non-smokers. The greater the amount of smoking, the higher the chance of pancreatic cancer. For example, if you smoke 1 pack a day, pancreatic cancer occurs 4 and 2 times higher than that of non-smokers. The above data indicates that smoking in some people can induce pancreatic cancer.
Inappropriate diet (5%):
In recent years, some scholars have attributed the increase of pancreatic cancer to the improper diet structure. Animal experiments have shown that animals fed with high protein and high fat diet can accelerate the regeneration of pancreatic ductal cells and increase the sensitivity to carcinogens. Scholar Shen Kui and other clearly stated that the diet structure is closely related to the occurrence of pancreatic cancer, and many people eating meat are prone to this disease. Japanese scholars pointed out that the increase in the incidence of pancreatic cancer in Japan in recent years is related to the Europeanization of Japanese diet, that is, eating high protein. There is too much high fat, and some scholars believe that there is more chance of pancreatic cancer in coffee, but it has not been further confirmed.
Diabetes and pancreatic cancer (15%):
People with diabetes are prone to pancreatic cancer. However, in recent years, it has been pointed out that people with diabetes mellitus have twice as many pancreatic cancers as non-diabetic patients, and there is an increasing trend. Some people think that it is 2 to 4 of the normal population. Times, even there are reports that the incidence rate can reach 12.4% of digestive system malignancies, but the true relationship between the two is not clear.
Chronic pancreatitis and pancreatic cancer (25%):
As early as 1950, Mikal et al. noticed the relationship between chronic pancreatitis and pancreatic cancer. In 1960, Panlino-Netto pointed out that only patients with chronic pancreatitis with pancreatic calcification existed simultaneously with pancreatic cancer. In 1977 White further pointed out that in the primary Only 3 cases of chronic calcified chronic pancreatitis with pancreatic cancer accounted for 2.2%. Chronic pancreatitis and diabetes may be related to the occurrence of pancreatic cancer. Chronic pancreatitis often coincides with pancreatic cancer, according to Mikal et al. (1950) Reported 100 cases of autopsy, 49% showed chronic pancreatitis under the microscope, 84% had pancreatic interstitial fibrosis, and pancreatic duct obstruction caused by pancreatic cancer, which led to pancreatitis, so the two became Causality is difficult to determine. Some people think that calcified foci have carcinogenic effects in chronic pancreatitis with old calcification. Panlino-Netto (1960) reported that only pancreatic calcification patients, pancreatitis and pancreatic cancer exist simultaneously, but in White In the case of pancreatitis (1977), there were primary calcifications, and only 3% had cancer.
In addition, pancreatic cancer can occasionally undergo calcification. As for the relationship between pancreatic cancer and diabetes, it is not very clear. About 5% to 20% of patients with pancreatic cancer are accompanied by diabetes, and 80% of them have found diabetes in the same year. Pancreatic cancer, a large number of cases have also proved that 5% to 19% of cancer patients with cancer occur in the pancreas, while non-diabetic patients only 4% of cancer occurs in the pancreas, indicating that diabetic patients seem to be prone to pancreatic cancer, Sommers, etc. 1954) reported that 28% of patients with diabetes had pancreatic duct hyperplasia, while only 9% of the control group had pancreatic duct hyperplasia. It is envisaged that cancer can occur on the basis of pancreatic duct hyperplasia. Bell (1957) reported the autopsy of men over 40 years old. In 32,508 cases, the incidence of pancreatic cancer in diabetic patients was more than double that of non-diabetics, but there is some evidence that the incidence of pancreatic cancer has no significant relationship with diabetes. According to Lemass (1960), patients with pancreatic cancer and diabetes, There is no pathological change in the destruction of islet cells. Some patients with pancreatic cancer may have some degree of damage to glucose metabolism, which may be due to the absence of pathological changes in islet cells. But the release of insulin by the interference of some kind of reason, also suggested that pancreatic diabetes is not its particularity, the incidence of diabetes in the general population is also up to 10%.
(1) Causes of the disease
The etiology of pancreatic cancer is not well understood. Pancreatic cancer occurs in association with smoking, drinking, high-fat and high-protein diets, excessive coffee consumption, environmental pollution and genetic factors. Recent investigations have found that the incidence of pancreatic cancer is significant in diabetic populations. It is higher than the general population; some people have noticed that there is a certain relationship between the patients with chronic pancreatitis and the incidence of pancreatic cancer. It is found that the proportion of pancreatic cancer in patients with chronic pancreatitis is significantly increased; in addition, there are many factors related to the occurrence of this disease, such as Occupation, environment, geography, etc.
1. Gene abnormal expression and pancreatic cancer
Recently, there are many genetic studies on the occurrence of pancreatic cancer. The abnormal expression of genes is closely related to the occurrence of pancreatic cancer. The relationship between the occurrence of various tumors and cellular genes is a hot spot for studying the causes of cancer. Among the gene families, K- The mutation of the ras gene at 12 sites is closely related to the occurrence of pancreatic cancer, and the inactivation of the tumor suppressor gene P53 and the recently cloned MTS1 also has an effect. Since cancer is a multifactorial process, there may be multiple cancers. The activation and inactivation of genes or tumor suppressor genes are not related to family inheritance.
In 1991, Tada et al. detected 12 cases of patients with pancreatic cancer and 6 patients with chronic pancreatitis. The PCR test was used to detect the 12 codons of c-ki-ras in 12 pancreatic patients. The author further pointed out that the change of c-ki-ras 12 codon is mainly a base mutation, and Tada et al. proposed that c-ki-ras mutation position and carcinogenic factors are different after animal test, smoking The c-ki-ras 12-site mutation can be induced, while other carcinogens such as dimethylbenzopyrene cause the 61-site codon mutation of H-ras gene. After analyzing the clinical situation of Tada patients with pancreatic cancer, It is considered that the c-ki-ras gene mutation has no obvious relationship with the degree of tumor differentiation, but it is related to the size of the tumor, so that the c-ki-ras gene mutation mainly promotes the progression of the tumor, and the Lemocene study finds that the change indicates that the pancreatic ductal epithelial cells are in the pancreatic duct. The c-ki-ras gene changes first, that is, the c-ki-ras gene changes cause pancreatic ductal epithelial cells to become cancerous, and then the cancer cells infiltrate outward. There are few studies on pancreatic cancer occurrence and genetic alteration, many problems Pending Further study.
2, endocrine disorders
The occurrence of pancreatic cancer may also be related to endocrine, which is based on the incidence of men higher than that of women before menopause, and the incidence of women after menopause increases, similar to men, and the incidence of women with a history of spontaneous abortion is also higher. .
3, the role of bile
It has been thought for many years that bile contains carcinogenic factors. Because bile can flow back to the pancreatic duct, and pancreatic tissue is more sensitive to carcinogenic factors than bile ducts, pancreatic cancer is more common than cholangiocarcinoma. At the same time, in pancreatic cancer, exposure to bile More chances of the pancreatic head, the incidence of cancer is higher, and cancer originates from the catheter rather than the acinus, which also indicates that this view has a certain basis.
(two) pathogenesis
1, the lesion
Primary pancreatic cancer can occur in any part of the pancreas, but it is most common in the head of the pancreas. According to a large number of cases, the head of the pancreas is about twice as large as the tail of the pancreas, that is, pancreatic cancer accounts for 60%. ~70%, pancreatic body tail cancer accounts for 25% to 30%; in a few cases, cancer spreads throughout the gland, and it is difficult to determine its location, Bramhall and other studies found that 80% to 90% of surgically treated pancreatic cancer The mass is located in the head of the pancreas. The recent report from the Pancreatic Cancer Committee of the Chinese Anti-Cancer Association showed that pancreatic head cancer accounted for 70.1%, the tail of the pancreas was 20.8%, and the pancreatic cancer accounted for 9.1%.
2, gross pathology
The macroscopic appearance of pancreatic cancer is inconsistent. The general morphology of the pancreas depends on the course of the disease and the size of the cancer. When the cancer is not large, the tumor is deep in the pancreas and cannot be seen from the surface of the pancreas. There is a feeling of irregular nodules at the time of diagnosis. When the cancer is enlarged, the shape of the pancreas changes, and there is a localized swelling of the tumor in the head or tail of the pancreas. The boundary between the tumor and the surrounding pancreatic tissue is not very clear. Pancreatic cancer on the cut surface is mostly gray or yellowish white irregular shape, can also be yellowish white or grayish white, also can be seen with brown or brown red bleeding spots or necrotic foci, turbidity can be seen in liquefied carcinoma Brown-brown mucous fluid, some of which are small cystic cavity. The pancreas itself is often accompanied by increased fibrous tissue, which makes it firm in texture, and some have pancreatic atrophy. Localized fat necrosis can be seen in the pancreas. It is due to cancer, pancreatic duct obstruction, pancreatic duct rupture, pancreatic juice overflow, causing local fat necrosis in the pancreas. The size of pancreatic cancer varies greatly, which is related to the length of the disease. The diameter of the general mass is often above 5cm. Most of the cancers in the head of the pancreas are extremely hard. There is no obvious boundary between the cancerous tissue and the normal glandular tissue. Sometimes this hard cancer can infiltrate the peripancreatic tissue extensively, and the pancreatic adhesion can not be recognized in a group of cancerous tissues; but sometimes cancer The tissue can also be located in the central part of the pancreas. The appearance is the same as that of the normal pancreas. Only the head of the pancreas is particularly hard. The fibrous tissue is also proliferated on the cut surface and the glandular tissue is significantly reduced, which is difficult to distinguish from chronic pancreatitis.
Pancreatic cancer can be derived from pancreatic duct, acinar or islet. Usually pancreatic cancer is derived from pancreatic duct epithelium, accounting for 85% of the total cases, and less from acinar and islet; the former mainly occurs in the pancreatic head. The latter is often in the pancreas or tail.
3. Histological changes
The microscopic findings of pancreatic cancer mainly depend on the degree of differentiation of adenocarcinoma tissues. The well-differentiated people form a more mature tubular tissue of the pancreatic gland. The cells are mainly high cubes, similar in size, rich in cytoplasm, similar in nucleus, and mostly located at the bottom. Polarized distribution, poorly differentiated can form various forms or even form a glandular tubular structure, and become a solid strip-like, nest-like, flaky, cluster-like diffuse infiltration, cell size and shape are different, can be presented Spherical, circular, or polygonal, the boundaries are not clear, the nuclear position is not the same, the nuclear staining is deep, no nucleoli, the pancreatic duct-like structure of pancreatic cancer is irregularly arranged, and the epithelial cells are arranged in layers, and the nucleus The position of the pancreatic duct epithelial hyperplasia and papillary-like protrusion, but the papillary structure, called papillary pancreatic cancer, even the appearance of goblet cell metaplasia, also visible squamous cell metaplasia, under the electron microscope, visible viscosity Mucinogen granules, but not zymogen granules, are derived from larger pancreatic ductal epithelial cells. When squamous cell degeneration is obvious, it is called adenoid squamous cell carcinoma (adenosquamous). Cell carcinoma), or adenochonoma (adenocanthoma), microscopic examination of varying degrees of focal hemorrhage, necrosis and steatosis, called cystic adenocarcinoma, such as with pancreatic duct obstruction, pancreatic acinar atrophy, with nipple Like hyperplasia.
4. Pathological staging of pancreatic cancer
The vast majority (>80%) of pancreatic cancers originate from ductal epithelial cells, in which adenocarcinoma of the pancreatic ductal epithelial cells from the pancreas is predominant, and a small number of pancreatic ductal epithelial cells from the pancreas come from Pancreatic cancer of large, medium and small pancreatic ducts, because of its hard texture, is collectively referred to as hard cancer. Pancreatic cancer originating from pancreatic vesicle cells is rare, and the cancerous tumor is soft and mellow.
(1) Japanese Pancreas Association Recommended Standard
Japanese Pancreas Association recommended standard T1 ~ T4 T1 tumor diameter 2.0cm, T2: 2.1 ~ 4.0cm; T3: 4.1 ~ 6.0cm; T4> 6.0cm, N shows lymph node involvement; N0 is no lymph node involvement; N1 is Nerve lymph node involvement; N2 has secondary lymph node involvement; S3 shows pancreatic capsule involvement: S0 refers to pancreatic capsule not invaded, S1 refers to pancreatic capsule infiltration, S2 refers to There must be an infiltration of the pancreatic capsule, S3 refers to the infiltration of the organs around the pancreas, Rp shows post-peritoneal involvement: Rp0 shows no post-peritoneal involvement, Rp1 suspected retroperitoneal involvement, Rp2 must have retroperitoneal involvement, Rp3 shows severe retroperitoneal Invasion, V shows the involvement of the peri-pancreatic vessels, mainly refers to the portal vein, superior mesenteric vein, and splenic vein involvement: V0 means no vascular involvement, V1 suspected vascular involvement, V2 must have vascular involvement, V3 blood vessels are seriously violated, Japanese pancreatic cancer The association divided the lymph nodes around the pancreas into 18 groups, 3 stations.
(2) TNM staging
The pathological staging of pancreatic cancer contributes to the choice of treatment options and prognosis assessment. TNM staging is commonly used. The following is the latest revision of the 2002 International Anticancer Association (UICC) and the Japanese Pancreatic Disease Association (JPS). The Staging Standard for the Cancer Alliance (AJCC) is roughly the same as the UICC standard. The sixth edition of the UICC Staging (2002).
1T stage: Tx: primary tumor cannot be determined; To: no primary tumor evidence; Tis: carcinoma in situ (including Pan In III); T1: tumor is confined to the pancreas 2 cm; T2: tumor is confined to the pancreas > 2 cm; T3 : The tumor has extra-pancreatic infiltration, but does not invade the celiac trunk and superior mesenteric artery; T4: The tumor invades the celiac trunk and superior mesenteric artery (the primary tumor cannot be removed).
2N staging: Nx: local lymph node metastasis could not be determined; No: no local lymph node metastasis; N1: local lymph node metastasis.
3M staging: Mx: distant metastasis cannot be determined; Mo: no distant metastasis; M1: distant metastasis.
(3) JPS staging:
1T stage: Tis: carcinoma in situ; T1: tumor is confined to the pancreas 2cm; T2: tumor is confined to the pancreas > 2cm; T3: tumor invades the biliary tract, duodenum or other peripancreatic tissue; T4: tumor invades any of the following Item - adjacent to large blood vessels (such as the portal vein, arteries), away from the pancreas or other organs.
2N staging: No: no lymph node metastasis; N1: first station lymph node metastasis; N2: second station lymph node metastasis; N3: third station lymph node metastasis.
3M staging: Mo: no distant transfer; M1: distant transfer.
5. Metastasis of pancreatic cancer
Because of its rapid growth, pancreatic cancer is located in the retroperitoneum, surrounded by important organs, combined with pancreatic blood vessels, lymphatic vessels are abundant, pancreas has no capsule, often metastasizing early, or directly invading the pancreas, or lymphatic Tubes and/or blood vessels are transferred to distant and near organ tissues. The most frequently invaded sites are common bile duct, duodenum, liver, stomach, transverse colon and upper abdomen. In addition, pancreatic cancer can also be transferred outward along the nerve sheath. The pancreas happens to be lying in front of many nerve plexuses in the upper abdomen, so that the cancer tends to invade these nerve tissues at an early stage. Especially after the abdominal wall nerve tissue is most susceptible, it is because pancreatic cancer is easily spread directly in the local area, or lymphatic. , blood vessels and nerves spread outward, which constitutes its diverse clinical manifestations, so clinically advanced or advanced patients, or due to organs, blood vessels, nerve infiltration, or lymph node metastasis, can not be radical resection Even if it can be palliative resection, it will die due to recurrence in the short term after surgery. The metastasis of pancreatic cancer mainly depends on the following ways:
(1) Intra-pancreatic spread: Pancreatic cancer can penetrate the wall of pancreatic duct in the early stage, and infiltrate into the surrounding pancreatic tissue by invasive ductal carcinoma. Under the microscope, the infiltration of cancer tissue is limited to 2.0 to 2.5 from the edge of the tumor. Within cm, rarely more than 3.0cm, due to anatomical relationship, about 70% of pancreatic head cancer has invaded the uncinate process.
(2) peripancreatic tissue, organ infiltration: pancreatic cancer can infiltrate and spread to surrounding tissues, and the infiltration of the lower end of the common bile duct is a manifestation. In addition, the duodenum, stomach, transverse colon, spleen, etc. can also be tired. However, it is not necessary to penetrate the gastrointestinal tract to cause mucosal ulcers. Once the pancreatic body and tail cancer invade the peritoneum, extensive peritoneal transplantation can occur. According to the statistics of 621 cases of pancreatic head cancer in the Pancreatic Surgery Group of the Chinese Medical Association, peripancreatic tissue, The frequency of organ invasion was: 50.9% behind the pancreas, 39.8% of the superior mesenteric vein, 29.3% of the portal vein, 23.8% of the superior mesenteric artery, 21.1% of the duodenum, 15.3% of the bile duct, 8.9% of the transverse colon, 8.7% of the stomach, and splenic vein. 5.6%.
(3) Lymphatic metastasis: Lymphatic metastasis is the most important metastasis pathway in early pancreatic cancer. The lymph node metastasis rate of pancreatic head cancer is 65%-72%, mostly occurs under the pylorus, behind the pancreatic head, before the pancreatic head, next to the superior mesenteric vein. , hepatic artery, hepatoduodenal ligament lymph node, lymph node metastasis rate and tumor size and peripancreatic invasion degree are not directly related, about 30% of small pancreatic cancer has lymph node metastasis, a small number of lymph node metastasis can occur, Nagai et al studied 8 specimens of early pancreatic cancer. Four of the T1 patients had lymph node metastasis, and 4 patients had lymph node metastasis in T2. The lymph node metastasis rates of the pancreatic cancer were: No.13a, 13b. 30% to 48%, No. 17a, 17b is 20% to 30%, No. 12 is 20% to 30%, No. 8, 14a, 14b, 14c, 16 is 10% to 20%, pancreatic body tail Cancer mainly metastasizes to the pancreatic spleen lymph node group, and can also invade the stomach, liver, abdominal cavity, mesentery, aorta, and even the mediastinum and parabronchial lymph nodes, but the supraclavicular lymph nodes are not often involved.
(4) Neurotransmission: In advanced or advanced pancreatic cancer, it is often accompanied by nerve infiltration of the extra-pancreatic plexus behind the pancreas. The spread along the plexus is a unique metastasis of pancreatic cancer. The cancer cells can directly destroy the perineurium or enter The perivascular membrane is invaded into the interstitial space of the nerve bundle and spreads along the gap; or it penetrates into the extramedullary canal to form a new metastatic lesion. The neurotransmission of the pancreatic head cancer occurs mostly in the pancreatic head. The anterior and posterior, abdominal cavity, common hepatic artery, splenic artery and superior mesenteric artery constitute the main way of retroperitoneal infiltration, and also become the main cause of residual peritoneal tumor tissue. The lymphatic vessels around the retroperitoneal nerve are infiltrated. Persistent back pain is clinically important. The plexus metastasis is parallel with the infiltration of the pancreatic tissue and the degree of arterial infiltration, and is closely related to the size of the tumor. According to statistics, T1 tumors do not see extra-pancreatic plexus infiltration, while T3 Tumor extrapyramidal plexus infiltration rate of 70%.
(5) blood transfer and planting metastasis: the main metastasis mode of most advanced pancreatic head cancer, and pancreatic body, tail cancer can have spleen vascular erosion in the early stage, the most common blood transfer is through the portal vein to the liver, from The liver passes through the vein to the lungs, and then to the adrenal gland, kidney, spleen and bone marrow. At the time of autopsy, about 2/3 of the cases have liver metastasis, especially the pancreatic body and tail cancer are easy to have extensive metastasis. Pancreatic cancer is also often spread. In the abdominal cavity, the small omentum is planted and transferred.
6, late stage pancreatic cancer
Pancreatic cancer has been extensively destroyed in the late stage of pancreatic cancer, but it is rare to have diabetes. Because islet cells can remain intact for a long time, and even proliferate more normally. Occasionally, cancer derived from pancreatic acinus can Secretion of a large number of lipases, which can cause extensive necrosis of adipose tissue in the subcutaneous or intra-marrow, sometimes pancreatic cancer can be accompanied by extensive thrombophlebitis in the body.
Malignant tumors are multi-factorial and have undergone multiple stages of complex pathological processes. In recent years, the development of molecular biology technology has deepened the understanding of the molecular mechanisms of malignant tumors and their evolution, prompting people to explore the nature of pancreatic cancer from the molecular level. And gradually formed a molecular pathology of cancer, the existing research found that pancreatic cancer involves the activation of proto-oncogenes and the inactivation of tumor suppressor genes, wherein the proto-oncogene K-ras activation is up to 90% in pancreatic cancer, which is believed to lead to pancreatic cancer. Independent molecular events occur, and other genes such as the tumor suppressor genes P53, P16, PTEN, and BRCA2 are inactivated to varying degrees in pancreatic cancer tissues.
Prevention
Pancreatic cancer prevention
1, primary prevention
At present, there is no specific preventive measure for the prevention of pancreatic cancer. Therefore, the primary prevention focuses on the prevention of possible causes and risk factors and the improvement of the health of the body.
Epidemiological survey data suggest that the incidence of pancreatic cancer is closely related to smoking, excessive intake of fat and protein in the diet, alcoholism and other unhealthy lifestyles and irrational nutrition.
Therefore, in order to avoid or reduce the occurrence of pancreatic cancer, it should be done:
(1) Stop drinking
Although there is no final conclusion on whether drinking alcohol can cause pancreatic cancer, reducing alcohol consumption, especially if you drink less or not alcohol, can prevent pancreatitis and may also avoid or reduce the possibility of pancreatic cancer. In addition, avoid the combined effects of smoking, drinking and eating a high-fat, high-protein diet.
(2) Quit smoking
In particular, educate young people not to smoke. The amount of cigarettes smoked per day and the length of the smoke are positively correlated with the occurrence of pancreatic cancer. Those who smoke from adolescence are more likely to develop pancreatic cancer.
(3) Promote low-fat, low-protein, high-fiber and high-vitamin diets
Gold and other found that fresh fruits and vegetables can prevent the occurrence of pancreatic cancer. A survey by Correa et al. in Los Angeles also showed that fruit or orange juice (containing vitamin C) can significantly reduce the incidence of pancreatic cancer. Farrow and Davis's research suggests that fruits, vegetables, and vitamins A and C have nothing to do with the incidence of pancreatic cancer, and that increased calcium intake reduces the risk of developing pancreatic cancer, especially for men over 65 years of age. . Some data indicate that the high calorie diet caused by the increase in the proportion of sugar in the diet is positively correlated with the occurrence of pancreatic cancer, while the long-term high-fiber diet is negatively correlated with the occurrence of pancreatic cancer.
In addition, to reduce the consumption of coffee, especially to avoid decaffeinated coffee.
(4) Reduce environmental pathogenic factors
Good environmental factors play an important role in preventing pancreatic cancer. Radioactive materials should be reduced or avoided, and good protective measures should be taken for personnel engaged in radioactive work. Opportunities for viral infections should be reduced, especially for epidemic viral infections. Avoid prolonged exposure to substances associated with pancreatic cancer, such as certain metals, coke, gas, asbestos, elixir, beta-naphtholamine, benzidine, methylcholine, N-nitrosomethylamine, acetamido Deuterium and hydrocarbons, etc., and take good protective measures as much as possible.
(5) reduce or prevent the occurrence of related diseases
In order to reduce the incidence of pancreatic cancer, appropriate measures should be taken to prevent diabetes, chronic pancreatitis and cholelithiasis. Improve women's health care and avoid multiple abortions, oophorectomy and endometrial hyperplasia. Correct all kinds of endocrine disorders in time.
2, secondary prevention
(1) Early diagnosis
Pancreatic cancer can be detected early in the general population over 40 years of age. The census means can rely on CA19-9 monoclonal antibody, which is characterized by high sensitivity and positive rate of pancreatic cancer of more than 90%. Therefore, patients with positive CA19-9 monoclonal antibody should be reviewed regularly. First, B-ultrasound diagnosis, if necessary, ERCP, EUS and other in-depth examination, found that pancreatic mass can be used for B-ultrasound guided percutaneous fine needle biopsy, routine examination of the negative EUS often found small pancreatic cancer. For those with a family history of pancreatic cancer, CA19-9 and B-ultrasound should be checked regularly.
(2) early treatment
Early surgery is currently the main method for the treatment of pancreatic cancer. At the same time, comprehensive treatment of traditional Chinese and Western medicine should be actively adopted.
Complication
Pancreatic cancer complications Complications diabetes
Can be complicated by bile duct obstruction, duodenal obstruction and other symptoms, tumor caused by splenic vein obstruction can cause splenomegaly and localized portal hypertension, causing gastric bleeding or esophageal varices.
1, weight loss
The weight loss caused by pancreatic cancer is the most prominent, and there is obvious weight loss in the short term after the onset, and the weight loss can reach more than 30 kg, accompanied by weakness and weakness.
2, symptomatic diabetes
The initial manifestation of a small number of patients is the symptoms of diabetes. Therefore, if the diabetic patient has persistent abdominal pain, or the elderly suddenly develop diabetes, or the original diabetes, and suddenly the condition suddenly worsens, you should be alert to the possibility of pancreatic cancer.
3, thrombophlebitis
Patients with advanced pancreatic cancer develop migratory thrombophlebitis or arterial thrombosis.
4, mental symptoms
Some patients with pancreatic cancer can express mental symptoms such as anxiety, impatience, depression, and personality changes.
Symptom
Pancreatic cancer symptoms Common symptoms Left upper abdominal cystic mass has tenderness jaundice weight loss painful appetite nausea abdominal discomfort constipation back pain right upper quadrant pain
Pancreatic cancer has no specific initial symptoms, and there are no very specific signs. The clinical manifestations depend on the location of the cancer, the course of the disease is sooner or later, the presence or absence of metastasis and the involvement of adjacent organs. The clinical features are that the whole course is short, the disease develops rapidly and rapidly deteriorates. The most common is the upper abdominal fullness discomfort, pain, if the middle-aged person over 40 years old complained of upper abdominal symptoms, in addition to considering liver and gallbladder, gastrointestinal diseases, should consider the possibility of pancreatic cancer, although there is conscious pain, but tenderness and Not all patients have it. If there is tenderness, it is consistent with the part of the conscious pain.
1, abdominal pain
Pain is the main symptom of pancreatic cancer, and regardless of whether the cancer is located in the head or tail of the pancreas, 60% to 80% of patients present with upper abdominal pain, and 85% of these patients with pain have been unable to be surgically removed or It is already in the advanced stage. The pain is generally not related to diet. At first, most of them are lighter, and the persistent pain is gradually worsened. Because of the different parts of the cancer and the mechanism of pain caused, the abdominal pain can be manifested in various manifestations, the degree of which is caused by fullness and discomfort. Even severe pain, radiation pain, pancreatic head cancer mostly to the right side, while body-tail cancer is mostly radiated to the left side, low back pain indicates a more advanced and poor prognosis.
Pancreatic cancer can increase the pancreas due to cancer, oppress the pancreatic duct, cause obstruction of the pancreatic duct, dilatation, distortion and increased pressure, causing persistent or intermittent pain in the upper abdomen, sometimes accompanied by pancreatitis, causing visceral neuralgia. The nerve impulse is transmitted through the splanchnic nerve to the left and right T6T11 sympathetic ganglia, so the early stage of the lesion often presents a wide range of mid-upper abdomen, but it is difficult to locate and the nature is vague, full of discomfort, dull or dull pain, etc. After eating for 1 to 2 hours, the fear is reduced to reduce the pain caused by eating. The less common is paroxysmal upper abdominal pain, and it is progressively worse or even unbearable. This is more common in early stage cancer of the head. Pancreaticobiliary obstruction, due to drinking or eating greasy food induced bile and pancreatic juice excretion increased, resulting in biliary tract, pancreatic duct pressure caused by sudden rise, pancreatic blood vessels and nerves are very rich, and adjacent to the retroperitoneal plexus, so when the lesions expand, When metastasis affects the peritoneum, pancreatic head cancer can cause right upper quadrant pain, pancreatic body tail cancer is left, sometimes it can also involve the whole abdomen, low back pain is common, and advanced disease is more severe. Or limited to the double-season rib banding, suggesting that the cancer is metastasized along the nerve sheath to the retroperitoneal plexus. The abdominal pain of typical pancreatic cancer is often aggravated when lying on the back, especially at night, forcing the patient to sit up or forward. Bending, knees in order to relieve pain, and sometimes often make patients sleepless at night, may be due to cancer infiltration and compression of the celiac plexus.
In addition to the middle abdomen or left upper abdomen, right upper abdomen pain, a few cases complained of left, right lower abdomen, umbilical or total abdominal pain, and even testicular pain, easily confused with other diseases, when the cancer involving the visceral capsule, peritoneum or retroperitoneum When organizing, there may be tenderness in the corresponding part.
2, Huang Wei
Astragalus is an important symptom of pancreatic cancer, especially cancer of the head of the pancreas. Astragalus is obstructive, accompanied by urinary deep yellow and clay-like stools. It is caused by invasion or compression of the lower end of the common bile duct. The jaundice is progressive, although there may be Slightly fluctuating, but it is impossible to completely subside. The temporary relief of jaundice is related to the regression of inflammation around the ampulla in the early stage. In the late stage, the jaundice produced by the ampullary tumor is more likely to occur due to the collapse of the tumor at the lower end of the common bile duct. Fluctuations, pancreatic body and tail cancer appear jaundice when it affects the head of the pancreas. In some patients with pancreatic cancer, jaundice is caused by liver metastasis. About one-fourth of patients have refractory skin itching, which is often progressive, although it is currently considered The occurrence of itching in obstructive jaundice may be related to the accumulation of bile acid in the skin, but a small number of patients without jaundice or mild jaundice may also have symptoms of itchy skin.
Nearly half of the patients can reach the enlarged gallbladder, which may be related to the obstruction of the lower biliary tract. Clinically, obstructive jaundice with gallbladder enlargement and no tenderness is called Courvoisier sign. It has diagnostic significance for pancreatic head cancer, but the positive rate. Not high, such as the original chronic gallbladder inflammation, the gallbladder can not be swollen, laparotomy and laparoscopic examination often shows gallbladder has been swollen, but no clinical signs, so the fistula and painless swelling of the gallbladder can not rule out the head of the pancreas Cancer, about 50% of patients have liver enlargement due to cholestasis, cancerous metastasis.
In the past, the diagnosis of pancreatic cancer often used painless jaundice as the first or necessary symptom of pancreatic cancer. The occurrence of jaundice is an important basis for the diagnosis of pancreatic cancer. Therefore, the chances of early diagnosis and surgery are often lost, but the painless jaundice is still the pancreas. The most common symptoms of cancer, about 50% of patients with this symptom have the opportunity to undergo radical surgery. The appearance of jaundice is closely related to the location of cancer. The cancer of the head of the pancreas often has jaundice. The jaundice may fluctuate and manifest itself as completeness. Or incomplete obstructive jaundice, cancer in the body or away from the bile duct, due to lymph node metastasis, compression of the extrahepatic bile duct or adhesion due to the vicinity of the bile duct, buckling, etc. can also cause jaundice.
3, digestive symptoms
The most common is loss of appetite, followed by nausea, vomiting, diarrhea or constipation or even nausea. Diarrhea is often steatorrhea, loss of appetite and obstruction of the lower common bile duct and pancreatic duct, and bile and pancreatic juice cannot enter the duodenum. Related, obstructive chronic pancreatitis of the pancreas leads to pancreatic exocrine dysfunction, which will inevitably affect appetite. A small number of patients develop obstructive vomiting because of tumor invasion or compression of the duodenum and stomach. Due to frequent eating, about 10 % of patients have severe constipation, and in addition, about 15% of patients have diarrhea due to exocrine dysfunction of the pancreas; steatorrhea is a late manifestation, a characteristic symptom of pancreatic exocrine dysfunction, but rare, pancreatic cancer can also occur Gastrointestinal hemorrhage, manifested as hematemesis, black stool or only fecal occult blood test, the incidence rate is about 10%, the cause of gastrointestinal bleeding is adjacent cavity organs such as duodenum or stomach invasion and rupture, ampulla Cancer itself is more prone to bleeding, splenic vein or portal vein embolism due to tumor invasion, secondary to portal hypertension, leading to esophageal varices Occurrence of ruptured major bleeding is also occasional.
4, weight loss, fatigue
Unlike other cancers, pancreatic cancer often has weight loss and fatigue in the early stage. This symptom has nothing to do with the cancerous tumor. In digestive tract tumors, the weight loss caused by pancreatic cancer is the most prominent, and obvious weight loss occurs shortly after the onset. Weight loss can reach more than 30 pounds, accompanied by symptoms such as weakness and weakness. Some patients show progressive weight loss before other symptoms appear. The reason for weight loss is due to loss of appetite, reduced eating, or appetite, but Reluctant to eat due to upper abdominal discomfort or abdominal pain after eating. In addition, pancreatic exocrine dysfunction or pancreatic juice is blocked by pancreatic duct drainage, affecting digestion and absorption function, and also has a certain relationship.
5, abdominal block
The pancreas is deep in the posterior abdomen. The abdominal mass is the result of the development of the cancer itself. It is located at the location of the lesion. If the mass has been touched, it is mostly in the advanced or advanced stage. Chronic pancreatitis can also touch the mass, and pancreatic cancer. It is difficult to identify. Pancreatic cancer can cause dilatation of the bile duct and gallbladder in the liver and the gallbladder in the liver, so the swollen liver and gallbladder can be touched. The shape of the cancer is irregular, the size is different, the quality is firm and fixed, and it can be obvious. Tenderness, because the head lesions of the pancreas often have other obvious symptoms before the appearance of the mass, so the abdominal mass caused by this disease is relatively more common in the tail and tail cancer. When the cancer changes the abdominal aorta or splenic artery, it can be in the umbilical cord. Or the left upper abdomen heard a whirlpool of blood vessels, sometimes the abdominal mass was a swollen liver and gallbladder, and pancreatic cancer complicated with pancreatic cysts.
6, symptomatic diabetes
The initial manifestation of a small number of patients is the symptoms of diabetes, that is, before the appearance of major symptoms of pancreatic cancer such as abdominal pain, jaundice, etc., the first diabetes, and the accompanying weight loss and weight loss are mistaken for the performance of diabetes, without considering Pancreatic cancer; can also be expressed as a long-term diabetic patients, the recent increase in the condition, or the original long-term treatment of the disease treatment measures become invalid, indicating that there may be pancreatic cancer on the basis of the original diabetes, so if the diabetes patients appear Sustained abdominal pain, or sudden onset of diabetes in the elderly, or pre-existing diabetes, and sudden sudden increase in the condition should be alert to the possibility of pancreatic cancer.
7, thrombophlebitis
Patients with advanced pancreatic cancer have migratory thrombophlebitis or arterial thrombosis. If there is deep venous thrombosis of the lower extremity, it can cause edema of the affected lower extremity. The autopsy data indicates that the incidence of arterial and venous thrombosis accounts for about 25%. More in the pancreatic body, tail cancer, Spain believes that cancer may secrete some substances that promote thrombosis, such as portal vein thrombosis can cause lower esophageal varices or ascites, splenic vein thrombosis can cause splenomegaly, these patients are easy to cause Acute upper gastrointestinal bleeding.
8, mental symptoms
Some patients with pancreatic cancer can express mental symptoms such as anxiety, impatience, depression, personality changes, etc., and the mechanism of its occurrence is still unclear. It may be due to the symptoms of refractory abdominal pain, inability to sleep, and inability to eat. influences.
9, other
In addition, patients often complain of fever, obviously fatigue, may have high fever or even chills and other symptoms similar to cholangitis, so easy to be confused with cholelithiasis, cholangitis, of course, there are biliary obstruction and infection, but also chills, high fever, part Patients may have small joint redness, swelling, pain, heat, subcutaneous fat necrosis around the joints and unexplained testicular pain. The supraclavicular, axillary or inguinal lymph nodes may also be swollen and hard due to pancreatic cancer metastasis.
Ascites usually occurs in the late stage of pancreatic cancer, mostly due to peritoneal infiltration of cancer, and spread. The traits of ascites may be bloody or serous. Hypoproteinemia of advanced cachexia can also cause ascites, but one thing to note is the pancreas. Cancer complicated by pancreatic cyst rupture to form pancreatic ascites, characterized by rapid rise after water release, ascites increased amylase, protein content is also high, at this time ascites does not mean the late stage of pancreatic cancer, so do not give up the opportunity for surgical treatment.
Early detection of pancreatic cancer, early diagnosis is an important factor in determining the therapeutic effect. Early patients with pancreatic cancer have no specific symptoms. The first symptom is easily confused with gastrointestinal and hepatobiliary diseases. Because some clinicians have insufficient understanding of early symptoms of pancreatic cancer, Or incomplete collection of medical history, analysis of one-sided, often missed or misdiagnosed, when there is jaundice or abdomen has touched the lumps for medical or surgical treatment, most patients have lost the opportunity for surgery or radical resection.
Examine
Pancreatic cancer examination
(1) Laboratory inspection
Serum bilirubin is significantly elevated, sometimes exceeding 342 mol/L, with elevated bilirubin as the main component. The increase in blood alkaline phosphatase value is also significant. The urinary bilirubin test was positive or strongly positive. Blood amylase determination, in a small number of early pancreatic cancer, due to pancreatic duct obstruction may have a transient increase; late pancreatic tissue atrophy, blood amylase value will not change. Patients with pancreatic cancer may have elevated fasting blood glucose and a high positive rate of glucose tolerance test. Carcinoembryonic antigen (CEA) assays, about 70% of patients with pancreatic cancer can be elevated, but also no specificity. The digestive tract cancer-associated antigen CA19-9 is considered to be an indicator for the diagnosis of pancreatic cancer.
(2) B-ultrasound
Direct images of pancreatic cancer can be seen in hypoechoic tumors. Indirect findings often lead to the discovery of small pancreatic cancer, such as dilated pancreatic ducts and bile ducts. In addition to the main pancreatic duct, the branches of the pancreatic duct should be carefully observed. Some small pancreatic cancer can first cause localized expansion of the pancreatic duct branch, such as the expansion of the pancreatic duct. Ultrasound endoscopy is performed by the ultrasound probe only on the stomach and the duodenal wall to scan the tail and head of the pancreas without interference from the gastrointestinal gas. Therefore, the structure of the pancreas can be clearly described and early lesions can be found.
(three) CT scan
CT scans can show the correct location and size of the pancreatic mass and its relationship with the surrounding blood vessels, but the imaging lesions of about 2/3 of the <2 cm pancreatic mass cannot be found in addition to costly factors. CT scans should be listed as the primary method for the diagnosis of pancreatic cancer.
The CT images of pancreatic cancer are: 1 a pancreatic mass with a general or localized mass. The center of the mass may have a low-density area with irregular contours. If the low-density area is large, it may be tumor necrosis or liquefaction; 2 the cancer may invade or compress the bile duct or pancreatic duct to expand it; 3 the cancer may invade And the pancreatic fat layer and the perivascular or inferior vena cava.
(4) Magnetic resonance imaging (MRl)
MRI can show abnormal pancreatic contours. According to the signal level of T1 weighted images, early local invasion and metastasis can be judged. MRI is excellent for judging pancreatic cancer, especially small pancreatic cancer confined in the pancreas and with or without peripancreatic proliferation and vascular invasion. CT scan is a better method for preoperative prediction of pancreatic cancer. But it is expensive.
(5) Endoscopic retrograde cholangiopancreatography (ERCP )
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Diagnosis
diagnosis
Diagnosis can be performed based on clinical manifestations and examinations.
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