Pancreatic cancer in the elderly
Introduction
Introduction to pancreatic cancer in the elderly Pancreatic cancer (Pancreatic carcinoma) mainly refers to pancreatic exocrine adenocarcinoma, which is the most common type of pancreatic malignant tumor, accounting for 1% to 4% of various body cancers, accounting for 8% to 10% of digestive tract malignancies. Generally speaking, when it comes to pancreatic cancer, it also refers to cancer around the ampulla. The former is the pancreas itself, while the latter includes the lower end of the common bile duct, the ampulla, duodenal papilla and pancreatic head. The malignant degree is the highest in pancreatic cancer. The number of pancreatic cancer is also the most, accounting for about 3/5; and because it is pancreatic cancer or periampullary cancer, clinical symptoms, signs, diagnosis methods, treatment methods, etc. are similar, so this chapter only focuses on pancreas cancer. basic knowledge The proportion of illness: 0.0025% Susceptible people: the elderly Mode of infection: non-infectious Complications: jaundice
Cause
The cause of pancreatic cancer in the elderly
(1) Causes of the disease
There is no conclusion about the etiology of pancreatic cancer. At present, there are two main theories, that is, carcinogens in the environment act on the pancreas and develop into cancer on the basis of chronic pancreatic diseases.
(two) pathogenesis
1. Distribution of pancreatic cancer
(1) Pancreatic cancer, more common, accounting for more than 2/3 of pancreatic cancer.
(2) Pancreatic body, pancreatic tail cancer, accounting for about 1/4 of pancreatic cancer.
(3) Pancreatic cancer, which accounts for about 1/20 of pancreatic cancer.
2. Histological classification
(1) Catheter cell carcinoma is the most common, accounting for about 90% of pancreatic cancer. Microscopically, it is mainly ductal-like structure with different degrees of differentiation, accompanied by abundant fibrous interstitial, because the tumor is hard and the boundary is unclear; most catheters The serum CEA and CA19-9 were positive, and it was found by molecular biological techniques that there was a point mutation in the 12th codon of Ki-ras oncogene in pancreatic cancer, accounting for 75%-100%. In invasive cancer tissues, C-erbB2 oncogene expression can be found.
(2) acinar cell carcinoma.
(3) Others such as pleomorphic adenocarcinoma, ciliated cell adenocarcinoma, mucoepidermoid carcinoma, squamous cell carcinoma, squamous cell carcinoma, papillary cystadenocarcinoma and islet cell carcinoma are rare.
3. Pancreatic cancer metastasis The pancreas itself has no capsule, so it is easy to spread and metastasize early, in the following ways:
(1) Lymphatic and hematogenous metastasis: Lymphatic metastasis is the main mode of early metastasis of pancreatic cancer, even if the diameter of the cancer tissue.
(2) Intra-pancreatic diffusion and involvement of pancreatic circumference: Most pancreatic cancer can penetrate the wall of pancreatic duct in the early stage, infiltrate and metastasize to pancreatic tissue, and most pancreatic cancer can invade the peripancreatic tissue in the early stage, due to different directions of invasion. Involved in the duodenum, stomach, jejunum, transverse colon, liver and spleen, adrenal gland, kidney, ureter, retroperitoneal tissue, etc., the main blood vessels involved are portal vein, inferior vena cava, abdominal aorta, superior mesenteric vessels, splenic veins, etc.
(3) Neurotransmission: Pancreatic cancer can still be transferred along the nerve bundle. Generally, the nerve in the pancreas is invaded first, and then spread along the nerve bundle to the nerve plexus outside the pancreas. Under the microscope, the nerve and its surroundings are invaded.
In conclusion, the biological behavioral characteristics of these pancreatic cancers constitute the result of low resection rate, difficulty in curing and poor efficacy.
Prevention
Elderly pancreatic cancer prevention
Third-level prevention
Primary prevention: For the cause, the incidence of pancreatic cancer is related to environmental factors, such as smoking, drinking, high fat in the diet, high animal protein, etc., so eat more fresh fruits, vegetables, quit smoking, alcohol, and reduce the incidence of pancreatic cancer. helpful.
Secondary prevention: early diagnosis of pancreatic cancer, including detailed medical history, for patients with general dyspepsia, need to be closely observed, or have no family history of diabetes, etc., should be further examined, seeking early detection, early diagnosis, early treatment.
Tertiary prevention: After the patient has established a clinical diagnosis, strive for early surgical resection, combined with radiotherapy, chemotherapy, biological treatment and other means to comprehensive treatment to prolong survival.
2. Risk factors and interventions
The pathogenesis and pathogenesis of pancreatic cancer have not yet been elucidated. Epidemiological survey data suggest that increased incidence may be associated with long-term smoking, high fat and high animal protein diet, alcoholism, drinking coffee, certain chemical carcinogens, endocrine and metabolic disorders, pancreas Chronic diseases and genetic factors are generally considered to be the result of long-term interactions due to multiple factors.
(1) Dietary factors: Epidemiological investigations show that the incidence of pancreatic cancer is related to the fat of animals in the diet. High triglyceride and/or high cholesterol, low-fiber diet may promote or affect the occurrence of pancreatic cancer. The incidence of pancreatic cancer was lower decades ago, but since the 1950s, with the spread of Westernized diet, the incidence has increased four-fold. When the human body ingests a high-cholesterol diet, some cholesterol is converted into epoxy in the body. The latter can induce pancreatic cancer, and in addition to high-fat diet, it can promote the release of gastrin, secretin, bile, cholecystokinin, and trypsin (CCK-PZ). Hormone is a potent pancreatic proliferative stimulator that can proliferate pancreatic duct epithelium, promote variability and promote cell renewal, and increase the susceptibility of pancreatic tissue to carcinogens. Some nitrosamines may have carcinogenic specificity in pancreatic organs. In addition, in recent years, it has been found that the risk of pancreatic cancer is increased by a factor of two compared with those who do not drink coffee every day. If you drink more than 3 cups per day, the risk is increased by 3 times. Coffee drinks contain one or several ingredients promote the role of pancreatic cancer.
(2) Drinking factors: The exact relationship between drinking and pancreatic cancer is still inconclusive. Some people think that the occurrence of pancreatic cancer is related to long-term drinking of large quantities of wine. The relative risk of drinking pancreatic cancer is about twice that of non-drinkers. The possible cause is that the alcohol can effectively stimulate the secretion of pancreatic cells, causing chronic inflammation of the pancreas, leading to pancreatic damage, or due to other carcinogens such as nitrosamines in alcohol.
(3) Smoking factors: Many studies have shown that smoking is closely related to the incidence of pancreatic cancer. The incidence of pancreatic cancer in smokers is 2 to 3 times higher than that of non-smokers. The average age of onset has been 10 or 15 years earlier. Related to the following factors:
1 When smoking, certain harmful components of tobacco or their metabolically active substances are absorbed by the bile duct and then flow back into the pancreatic duct under certain conditions to stimulate the epithelium of the pancreatic duct and eventually cause cancer.
2 Some carcinogens in tobacco, such as hydrocarbon compounds, nitrosamines, etc. can be quickly absorbed from the oral cavity, upper respiratory tract mucosa and lung tissue. After entering the blood, they are excreted through the pancreas. A small amount of nitrosamines in cigarette smoke can be metabolized in the body. It is a diisohydrin nitrosamine active carcinogen.
3 Nicotine in tobacco promotes the release of catecholamines in the body, resulting in a marked increase in blood cholesterol levels. In some ways, hyperlipidemia can induce pancreatic cancer, which is particularly evident in a large number of smokers who smoke more than 40 cigarettes per day.
(4) Environmental factors: Most scholars believe that occupational exposure to certain chemicals may cause carcinogenic effects on the pancreas, long-term exposure to certain metal coke, gas plant work, asbestos, dry cleaning, application of fat-reducing agents and exposure to -naphtholamine , benzidine, methyl cholestyramine, N-nitrosomethylamine, acetamido oxime hydrocarbons and other chemical agents, the incidence of pancreatic cancer has increased significantly. In recent years, it has been found that pancreatic ductal epithelial cells can metabolize certain chemicals. It is transformed into a substance with chemical carcinogenesis. In addition to secreting a large amount of sodium bicarbonate, pancreatic duct epithelial cells can transport fat-soluble organic acids and certain chemical carcinogens, causing carcinogen concentration in pancreatic acinar or adjacent pancreatic duct. Increased, thereby changing the intracellular pH concentration to induce pancreatic cancer.
(5) Endocrine and metabolic factors: The relationship between diabetes and pancreatic cancer is still not clear. It is generally believed that pancreatic cancer is often accompanied by chronic, obstructive pancreatitis and islet fibrosis. Therefore, pancreatitis and diabetes are only symptoms of pancreatic cancer. However, in hereditary, insulin-dependent, especially in women with diabetes, the incidence of pancreatic cancer is greatly increased. After multiple abortions, endocrine dysfunction and pancreatic cancer can occur after oophorectomy or endometrial hyperplasia. The increase in rate suggests that sex hormones may play a role in the pathogenesis of pancreatic cancer.
(6) Genetic factors: Genetic factors have a certain relationship with the onset of pancreatic cancer. Wyder et al reported that the incidence of black pancreatic cancer is higher than that of whites. The incidence of Jewish population in the United States is higher than other people. A brother and sister were reported. Three of them had pancreatic cancer at 54.48 or 55 years of age and were confirmed by surgery.
3. Community intervention
Because the early diagnosis of pancreatic cancer is difficult, community hospitals should popularize anti-cancer knowledge and regular physical examination, especially for the elderly over 50 years old.
Complication
Elderly pancreatic cancer complications Complications
The main complications are obstructive jaundice, liver, lung and bone metastasis.
Symptom
Elderly pancreatic cancer symptoms Common symptoms Anxiety, lack of appetite, progressive weight loss, pain, indigestion, upper gastrointestinal bleeding, right upper abdominal pain, back pain, abdominal discomfort
The clinical manifestations of pancreatic cancer depend on the location of the cancer, the course of the disease, the degree of pancreatic damage, the presence or absence of metastasis and the involvement of adjacent organs. The clinical features are that the whole course is short, and the disease progresses rapidly and rapidly deteriorates.
Abdominal pain
About half of the patients have abdominal pain. At first, most of them are milder and heavier. Pancreatic cancer can enlarge the pancreas due to cancer, compress the pancreatic duct, make the pancreatic duct obstruction, dilate, twist and increase the pressure, causing the upper abdomen to be persistent or intermittent. Pain, sometimes combined with pancreatitis, causing visceral neuralgia, early lesions often have a wide range of mid-upper abdomen but are difficult to locate and have a vague nature of fullness discomfort, dull or dull pain, etc., less common for bursts Severe upper abdominal pain, and progressive exacerbation, more common in early pancreatic head cancer with pancreaticobiliary obstruction, pancreatic head cancer can cause right upper quadrant pain, pancreatic body, tail cancer is left, sometimes can also involve the whole abdomen, back Common pain, advanced disease, low back pain is more intense, or limited to double-ribbed band, suggesting that the cancer is transferred along the nerve sheath to the retroperitoneal plexus. The abdominal pain of typical pancreatic cancer is often aggravated in the supine, especially in Especially at night, forcing patients to sit up or bend forward, knees to relieve pain, and sometimes make patients sleep at night, may be due to cancer infiltration and compression of the celiac plexus.
2. Weight loss
The weight loss caused by pancreatic cancer is prominent. After the onset, there is obvious weight loss in the short term. The weight loss can reach more than 15kg, accompanied by symptoms such as weakness and weakness. Some patients first show progressive weight loss. The reason for weight loss is due to loss of appetite and eating. Reduced, or although there is appetite, but because of upper abdominal discomfort after eating or abdominal pain is not willing to eat, in addition, pancreatic exocrine dysfunction or pancreatic juice through the pancreatic duct outflow blocked, affecting digestion and absorption, there is a certain relationship.
3. Huang Wei
Astragalus is an important symptom of pancreatic cancer, especially pancreatic head cancer. Astragalus is obstructive because of the invasion or compression of the lower end of the common bile duct. The jaundice is progressive, although it may have slight fluctuations, but it may not completely subside. Temporarily relieved, in the early stage, it is related to the regression of inflammation around the ampulla. In the late stage, due to the swelling and swell of the tumor invading the lower end of the common bile duct, the pancreatic body and the tail cancer appear jaundice when the pancreatic head is affected. Some patients with pancreatic cancer have jaundice in the late stage. Due to liver metastasis.
Nearly half of the patients can reach the enlarged gallbladder, which is related to the obstruction of the lower bile duct. 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 is not. High, such as the original chronic gallbladder inflammation, the gallbladder can not be swollen, so the gallbladder can not rule out pancreatic cancer.
4. Abdominal block
Most of the abdominal masses are late signs, the shape of the mass is irregular, the size is different, the quality is firm and fixed, and there may be obvious tenderness. The abdominal mass is relatively more common in the tail and tail cancer.
5. Other gastrointestinal symptoms
(1) symptoms of dyspepsia: in pancreatic cancer, especially in the main pancreatic duct or pancreatic cancer closer to the main pancreatic duct, obstructing the pancreatic duct, causing obstructive chronic pancreatitis, leading to pancreatic exocrine dysfunction; or the lower end of the common bile duct And the pancreatic duct is blocked by the tumor, bile and pancreatic juice can not enter the duodenum, causing dyspepsia symptoms. A small number of patients may have obstructive vomiting due to tumor invasion or compression of the duodenum and stomach. About 10% of patients have severe constipation. About 15% of patients have diarrhea; steatorrhea is a late manifestation, a characteristic symptom of pancreatic exocrine dysfunction, but rare.
(2) Upper gastrointestinal bleeding: about 10%, mainly due to the invasion of adjacent hollow organs such as the duodenum or stomach, which causes erosion or ulceration, and can still infiltrate the common bile duct or pot due to cancer. Abdominal, causing erosion or ulceration, causing acute or chronic bleeding, pancreatic body, tail cancer compression of the splenic vein or portal vein or embolism, secondary portal hypertension, resulting in esophageal varices rupture and bleeding.
6. Symptomatic Diabetes A small number of patients initially manifest as symptoms of diabetes; it can also be expressed as a long-term diabetic patients who have recently become more severe, so if diabetic patients have persistent abdominal pain, or the elderly suddenly develop diabetes, or Diabetes and sudden sudden increase in the condition should be alert to the possibility of pancreatic cancer.
7. vascular thrombotic disease about 10% to 20% of patients with pancreatic cancer have migratory or multiple thrombophlebitis, and this can be the first symptom, pancreatic body, pancreatic tail cancer has more chance of thrombophlebitis Most of them occur in the lower limbs and are more likely to occur in well-differentiated adenocarcinoma. The autopsy data indicates that the incidence of arterial and venous thrombosis accounts for about 25%, especially in the femoral vein. The most common femoral vein embolism, but no clinical symptoms appear. Arterial thrombosis is more common in the pulmonary arteries, but in the spleen, kidney, coronary arteries and cerebral arteries. Spain believes that cancer may secrete certain substances that promote thrombosis.
8. Psychiatric symptoms Some patients with pancreatic cancer can express anxiety, impatience, depression, personality changes and other mental symptoms. The mechanism of its occurrence is still unknown. It may be due to the intractable abdominal pain of patients with pancreatic cancer, the inability to sleep and the inability to eat. And emotions have an impact.
9. Acute cholecystitis or cholangitis about 4% of patients with pancreatic cancer with sudden onset of right upper quadrant with fever, jaundice and other acute cholecystitis or acute suppurative cholangitis as the first symptom, due to tumor compression, lower common bile duct obstruction Or caused by the merger of stones at the same time.
10. Abdominal vascular murmur When the cancer compresses the abdominal aorta or splenic artery, the vascular murmur can be heard in the umbilical or left upper abdomen, and the incidence rate is about 1%. It is generally considered that the appearance of vascular murmur is late. .
11. Other symptoms patients often complain of fever, obviously fatigue, some patients may have small joint red, swelling, pain, heat, subcutaneous fat necrosis around the joints and unexplained testicular pain, etc., supraclavicular, axillary or inguinal lymph nodes can also It is swollen and hard due to metastasis of pancreatic cancer.
12. Staging principle
(1) TNM staging of pancreatic cancer (AJCC1988, UICC1989):
T primary tumor
TX primary tumor cannot be determined
T0 did not see the primary tumor
T1 tumor is limited to the pancreas
T1a tumor maximum diameter 2cm
T1b tumor maximum diameter > 2cm
T2 tumors invade the duodenum, bile duct or tissue surrounding the pancreas.
T3 tumors invade the stomach, spleen, colon or nearby large blood vessels.
N lymph node
N0 has no local lymph node metastasis
N1 has local lymph node metastasis
M distant transfer
M0 has no distant transfer
M1 has a distant transfer
(2) Clinical stage:
Phase I T1 N0 M0
T2 N0 M0
Phase II T3 N0 M0
Phase III any T N1 M0
Phase IV any T any N M1
The preferred treatment for pancreatic cancer is surgical resection, but the resection rate is low due to difficulty in early diagnosis. However, in recent years, due to advances in diagnostic techniques, improvement in surgical techniques, improvement in preoperative and postoperative treatment, and development of adjuvant therapy, The 5-year survival rate after resection increased from 3.5% to the current 21% in the past 60 years, and the operative mortality rate dropped from the past 20% to the current 5% or lower.
Pancreatic cancer is a radiation-insensitive tumor, but it accounts for about 40% of cases with advanced limitations. It is suitable for pancreatic cancer to resist chemotherapy drugs, making chemotherapy less effective.
In recent years, through a large number of basic and clinical studies, comprehensive treatment based on surgical resection has been established, and the cure rate of pancreatic cancer has been further improved.
Characteristics of pancreatic head cancer: more common jaundice, abdominal pain often in the right upper abdomen, gallbladder and liver often swollen, X-ray or duodenoscopy often found lesions mainly in the duodenal descending or adjacent; pancreas Characteristics of body-tail cancer: jaundice is rare, gallbladder and liver are often not swollen, but abdominal pain is more prominent. Abdominal palpation and ultrasound can be found in the tumor. The positive rate of X-ray examination is low. If found, it is mainly in the duodenum. And duodenal curvature; total pancreatic cancer has multiple of the foregoing performance, and the general condition is worse.
Examine
Examination of pancreatic cancer in the elderly
1. Tumor marker detection
(1) Carcinoembryonic antigen (CEA): CEA is a tumor-associated antigen extracted from colon adenocarcinoma. It is a tumor embryonic antigen, a glycoprotein, digestive tract tumor such as colon cancer, pancreatic cancer, gastric cancer, lung cancer. The sensitivity and specificity of CEA for diagnosis of pancreatic cancer are low. Only 30% of patients with advanced pancreatic cancer can detect elevated serum CEA. A few reports of CEA sensitivity and specificity are 35% to 51, respectively. % and 50% to 80%, because normal people and chronic pancreatitis can have false positives, so elevated serum CEA level has only a reference value for the diagnosis of pancreatic cancer. It is reported that the pancreatic juice CEA is measured and combined with pancreatic juice cytology. The sensitivity of the diagnosis can be increased to 86%. CEA cannot be used as a screening test for asymptomatic people, nor as a method for early diagnosis of pancreatic cancer.
(2) Glycogen determinant CA19-9 (single ganglion sputum gastrointestinal tumor-associated antigen): a glycoprotein extracted from colon cancer cell lines, highly sensitive and relatively specific to pancreatic cancer Sex, normal human serum CA19-9 value is 8.4 ± 4U / ml, 37U / ml is the critical value, the sensitivity of diagnosis of pancreatic cancer is 79%, colon cancer is only 18%, and no increase in pancreatitis patients It is helpful to identify, recently introduced the application of immunoperoxidase method to detect CA19-9, the diagnostic accuracy of pancreatic cancer is up to 86%, the content of CA19-9 is positively correlated with the size of cancer, and the possibility of surgical resection at low level The sex is larger, and the prognosis of CA19-9 is significantly decreased to normal after tumor resection.
(3) Pancreatic carcinoembryonic antigen (POA): POA is the antigen of normal fetal pancreatic tissue and pancreatic cancer cells. The normal value is 4.0±1.4U/ml, and >7.0U/ml is positive. The literature reports that the increase of POA in patients with pancreatic cancer accounts for 73%, while the positive rates of gastric cancer and colon cancer were 49% and 33%, respectively. The sensitivity and specificity of pancreatic cancer diagnosis were 73% and 68%, respectively, but about 10% of cases of pancreatitis were false positive. It has certain reference value for the diagnosis of pancreatic cancer, but its specificity is not high, so it is still limited by its wide application.
(4) Pancreatic cancer-associated antigen (PEAA) and pancreas-specific antigen (PSA): PEAA is a glycoprotein isolated from the ascites of patients with pancreatic cancer. The upper limit of normal serum PEAA is 16.2 ng/L, and the positive for PCA of pancreatic cancer patients. The proportion of patients with stage I was 50%, but the positive rate of patients with chronic pancreatitis and cholelithiasis was as high as 50% and 38%, respectively, suggesting that the specificity of PCAA for diagnosis of pancreatic cancer is poor, and PSA is normal. The single-peptide chain protein extracted from human pancreas is an acidic glycoprotein, which is 8.2 g/L in normal people and >21.5 g/L. Pancreatic cancer patients have 66% of serum PSA-positive patients, and the positive rate of patients in stage 1 For 60%, the positive rates of patients with benign pancreatic diseases and cholelithiasis were 25% and 38%, respectively. The sensitivity and specificity of pancreatic cancer combined with PSA and PCAA were significantly higher than those of single tests, 90% and 85%, respectively. .
Glucose antigen-199 (CA-199) and pancreatic carcinoembryonic antigen (PEA) were detected by ELISA, and the specificity of malignant tumor-specific growth factor (TSGF) was detected by colorimetry. The positive rates were as follows: 85.4%, 87.5% and 83.3%, the positive rate of combined detection and diagnosis of pancreatic cancer was 100%. The dynamic detection of CA-199, PEA and TSGF is an important indicator for the diagnosis of pancreatic cancer, observing the efficacy of pancreatic cancer and judging the prognosis.
2. Other laboratory tests
(1) CCK-PZ and secretin test: after intravenous infusion of CCK-PZ and secretin, the pancreatic juice was collected through the duodenum, and the normal value was >90 ml after 80 min of injection of secretin, and the highest concentration of bicarbonate was > At 80mmol/L, the total amylase output after injection of CCK-PZ was >7500Somogyi U/80min. The main enzymes and bicarbonate concentrations of pancreatic cancer were significantly decreased.
(2) BT-PABA test: Oral synthetic peptide BT-PABA test is used to determine the secretion function of pancreatic chymase, the normal value is 63.52±10.53%, such as less than 30%, it is confirmed that pancreatic secretion is low, found in pancreatic cancer and chronic pancreas inflammation.
(3) Serum ribonuclease: It has been reported that 90% of patients with pancreatic cancer have elevated serum ribonuclease levels >250 U/ml (normal value <200 U/ml), because this enzyme has pancreatic properties and is markedly elevated in pancreatic cancer. High, it is considered that serum ribonuclease is a reliable biochemical indicator for the diagnosis of pancreatic cancer when kidney function is normal.
(4) lactoferrin (LF): LF is an iron-binding glycoprotein that can be used in a variety of exocrine fluids such as lotions, pancreatic juice, saliva, bile, bronchial secretions and special particles of neutrophils. Detection, detection of LF in pancreatic juice helps identify pancreatic cancer and chronic pancreatitis.
In recent years, due to the rapid development of imaging inspection technology and the advancement of experimental diagnostic methods, the diagnostic level of pancreatic cancer has improved, but the detection rate of early pancreatic cancer (tumor diameter 2cm, capsule is not invaded, no metastasis) Very low, still need to continue to explore.
3. X-ray inspection
(1) sputum angiography: low-end duodenal angiography is useful for the diagnosis of pancreatic cancer, because pancreatic cancer can affect adjacent cavity organs, causing displacement or invasion, the most common is duodenal drop The "pour 3 signs" on the side of the pancreas, but not common, only about 3% of patients are positive, pancreatic head cancer such as invasion of the duodenal wall, X-ray showed duodenal wall stiffness, mucosal destruction or lumen Stenosis, pancreatic head cancer can also cause gastric mucosal destruction. After pancreatic head cancer causes obstruction of the lower common bile duct, the thickened common bile duct and enlarged gallbladder can also compress and shift the duodenal bulb and transverse colon. The transverse part of the stomach and duodenum is pushed forward, and the transverse colon is displaced more downwards, or the gap between the large curvature of the stomach and the transverse colon is widened.
(2) Retrograde cholangiopancreatography (ERCP): The catheter is inserted into the ampulla from the ampulla of the ampulla to perform ERCP. The diagnosis rate of pancreatic cancer is 85%-90%, which is higher than B-ultrasound or CT. Early detection of pancreatic cancer, especially for the lower biliary tract and pancreatic duct obstruction, has a greater clinical significance. ERCP manifestations can be divided into obstructive, local stenosis, progressive stenosis and abnormal branching, etc., main pancreatic duct and gallbladder The advantage of the double tube sign is that it can observe whether the pancreatic head lesion infiltrates the duodenal papilla and the morphological changes of the pancreatic duct and bile duct. It is the most valuable method to show the pancreatic duct. (3) Selective celiac angiography: through The abdominal aorta is inserted into the celiac artery, the superior mesenteric artery and its branches are selectively contrasted, and the accuracy of selective angiography is about 90%. The pancreatic cancer is mainly characterized by intra-abdominal or peripanal artery, and the variation of vein morphology. Including the wall of the blood vessel is sawtoothed, narrow, angular, that is, displacement, interruption and obstruction.
(4) Percutaneous transhepatic cholangiography (PTC): can show the location of the bile duct obstruction, the degree and the identification of stones, such as intrahepatic bile duct dilatation, under the guidance of B-ultrasound, the puncture success rate is above 90%.
4. CT examination and MRI imaging
(1) CT examination: it is a non-invasive visualization technique, which can clearly observe the position, contour, tumor and other manifestations of the pancreas. The diagnosis rate of pancreatic cancer by CT is about 75%~88%, and the main performance of pancreatic cancer. For local lumps, the contour of the pancreas or pancreas is abnormally enlarged; the fat layer around the pancreas disappears; the head of the pancreas is lumps, the adjacent body, the tail edema; the cystic dilatation due to cancer necrosis or pancreatic duct obstruction is focal Density reduction zone.
(2) MRI imaging: MRI of pancreatic cancer shows an irregular image of T1 value, and the T1 value is higher in the center of the cancer. If there is biliary obstruction at the same time, it is considered to be a specific manifestation of pancreatic cancer, and there is a distinction between benign and malignant tumors. significance.
(3) MRCP (magnetic resonance cholangiopancreatography) is non-invasive, non-invasive, no serious complications, short inspection time, etc., no need to inject contrast agent, no X-ray damage, can clearly show bile duct and pancreatic duct The diagnosis rate of pancreatic cancer is similar to that of ERCP.
5. Ultrasound imaging
(1) B-mode ultrasound imaging: can understand the presence or absence of dilatation of the intrahepatic bile duct, the presence or absence of a mass at the lower end of the pancreatic head or common bile duct, the location of extrahepatic bile duct obstruction, the nature and extent of bile duct dilatation, and the ultrasound image of pancreatic cancer is a pancreatic limitation. Swollen or lobulated changes; edges are not clear, echoes are reduced or disappear.
(2) Endoscopic ultrasonography: it has great value in the diagnosis of pancreatic cancer, including early pancreatic cancer, and can make a certain diagnosis of the possibility of surgical resection. Ultrasound endoscopy of pancreatic cancer is as follows:
1 low echo substantial mass, irregular spots inside, round or nodular, rough edge of the tumor, typical lesions with a flame-like outer contour.
2 Pancreatic cancer infiltrates the surrounding large blood vessels, which is characterized by rough blood vessels and tumor compression.
6. Laparoscopy In the laparoscopic direct vision, the surface of the normal pancreas is yellow-white. Due to the special anatomical location of the head cancer, laparoscopy can only make a diagnosis based on indirect signs, which is characterized by a marked enlargement of the gallbladder, green liver. There are irregular lumps and deformations on the large curved side of the antrum, right reticular omental arteriovenous and pancreaticoduodenal varices and liver and abdominal metastasis. The direct signs of pancreatic and tail cancer are pancreatic masses. The surface has irregular small blood vessel hyperplasia with vascular interruption, stenosis and hard texture. The indirect signs are gastric coronary vein and gastric omentum varicose veins, retinal vascular dysfunction, green liver and gallbladder enlargement.
7. Pancreatic biopsy and cytology Preoperative or intraoperative fine needle aspiration pancreatic biopsy (FNA) is used to diagnose pancreatic cancer. Methods for obtaining pancreatic cells include:
1 through the duodenoscopy from the pancreatic duct, the duodenal wall directly puncture the pancreas;
2B ultrasound, CT or angiography guided percutaneous fine needle aspiration of pancreatic tissue;
3 Under the direct observation of the pancreas, Kim performed FNA examination on 30 patients with pancreatic lesions. The diagnostic accuracy was 80%, the specificity was 100%, the sensitivity was 79%, and the positive predictive value was 100%. One of the most effective methods of pancreatic cancer.
Diagnosis
Diagnosis and diagnosis of pancreatic cancer in the elderly
Differential diagnosis
1. Chronic pancreatitis with chronic upper abdominal distension, discomfort, dyspepsia, diarrhea, anorexia, weight loss, etc. The main clinical manifestations of chronic pancreatitis must be differentiated from pancreatic cancer, chronic pancreatitis often presents a chronic course, repeated History of acute attacks, diarrhea (or steatorrhea) is relatively rare, and jaundice is rare, and the condition is not progressively worsened or worsened. For example, X-ray abdominal plain film or B-mode ultrasound and CT examination found that the calcification point of the pancreas helps The diagnosis of chronic pancreatitis is sometimes difficult to identify. Even in the operation, the pancreas of chronic pancreatitis can be hard as a stone or a nodular change. If there is still difficulty in identifying the laparotomy, further deepening is required. Fine needle aspiration or pancreatic biopsy to identify.
2.Vater ampullary carcinoma and common bile duct carcinoma, Vater ampulla and pancreatic head are located adjacent to each other, and the three occur, obstruction caused by pancreatic head cancer and ampullary carcinoma, common bile duct cancer and common bile duct stones. The identification of jaundice, such as the clinical manifestations of tumors, is very similar, but in terms of surgical efficacy and prognosis, common bile duct and ampullary carcinoma are better than pancreatic cancer, so differential diagnosis is necessary.
