Pancreatic cancer is the fourth leading cause of cancer deaths in the US and typically affects older individuals in the sixth to eighth decades of life. Underlying risk factors include smoking, obesity, heavy alcohol consumption, and chronic pancreatitis. Pancreatic carcinomas are mostly ductal adenocarcinomas and frequently located in the pancreatic head. The disease is commonly diagnosed at an advanced stage because of the late onset of clinical features (e.g., epigastric pain, painless jaundice, and weight loss). In many cases, the tumor has already spread to other organs (mainly the liver) when it is diagnosed. Treatment is often palliative as surgical resection is only possible in approx. 20% of cases. The most commonly used surgical technique is the pancreaticoduodenectomy (Whipple procedure). Five-year survival rates range from 3–40% depending on the extent, spread, and resectability of the tumor.
- Age of onset: 60–80 years 
- Mortality: accounts for ∼ 8% of all cancer deaths in the US
High-risk groups 
- African Americans
- Individuals of Jewish ancestry
Epidemiological data refers to the US, unless otherwise specified.
Exogenous risk factors 
- Chronic pancreatitis (especially when present for more than 20 years)
- High alcohol consumption
- Type 2 diabetes mellitus
- Occupational exposure to chemicals used in the dry cleaning and metalworking industries
- Possibly infections with:
Endogenous risk factors 
- Age > 50 years
Inherited genetic syndromes (10% of pancreatic cancers)
- Familial atypical multiple mole melanoma (FAMMM) syndrome
- Hereditary breast and ovarian cancer syndrome (BRCA1 and BRCA2 mutations)
- Von-Hippel-Lindau syndrome
- Neurofibromatosis type 1
- Multiple endocrine neoplasia type 1
- Familial pancreatic carcinoma
- Hereditary pancreatitis (mutations in the PRSS1 gene)
- Peutz-Jeghers syndrome
In most cases, there are no early symptoms suggestive of pancreatic cancer. 
- Poor appetite
- Weight loss
- Belt-shaped epigastric pain which may radiate to the back
- Malabsorption, diarrhea (possibly steatorrhea secondary to exocrine pancreatic insufficiency)
- Jaundice caused by obstruction of extrahepatic bile ducts (especially in tumors of the pancreatic head)
- Impaired glucose tolerance (rarely)
- Trousseau syndrome: superficial thrombophlebitis (in 10% of cases)
- Thrombosis (e.g., phlebothrombosis, splenic vein thrombosis)
- No screening tests available
- Tumor markers: used to monitor the progression of cancer and treatment efficacy
- Possibly ↑ lipase
- Patients usually first undergo an ultrasound, especially if jaundice as the initial symptom.
- If abdominal pain and weight loss are the initial presenting symptoms, a CT scan is preferred. A contrast-enhanced abdominal CT is the investigation of choice to confirm pancreatic carcinoma and determine its resectability.
- If abdominal CT is inconclusive, or if the abdominal CT shows a borderline resectable or unresectable tumor, endoscopic ultrasonography (EUS) and EUS-guided biopsy should be performed to histologically confirm the diagnosis.
- In some cases, ERCP/MRCP may be considered to rule out choledocholithiasis and asses if biliary decompression is indicated.
- Abdominal ultrasound: usually the first test: , especially if jaundice is the presenting symptom
- Contrast-enhanced CT: usually confirms the diagnosis
- Endoscopic/magnetic resonance cholangiopancreatography (ERCP/MRCP)
- Endoscopic ultrasound (EUS)
- Fine needle aspiration: can be done via EUS (preferred) or percutaneously (US or CT-guided)
Pancreatic exocrine tumors 
Most common: ductal adenocarcinoma (95%)
- Altered ductal structures
- Cellular infiltration
- Less common
Pancreatic endocrine tumors (neuroendocrine tumors/NET) 
- Clinical features
- Asymptomatic cyst: no surgical treatment
- Symptomatic cyst: CT-guided, endoscopic, or surgical drainage
The differential diagnoses listed here are not exhaustive.
As the only curative treatment option for pancreatic cancer is surgical resection, patients with operable tumors (∼ 20%) are always recommended for surgery. If surgical tumor resection is not possible or distant metastasis is present, a palliative approach is chosen.
Curative approach 
- Pancreatic head carcinoma: (Whipple procedure)
- Pancreatic body and tail carcinoma
Neoadjuvant or adjuvant chemoradiotherapy
- To reduce tumor size, improve symptoms, and prolong life
- Chemotherapy or radiation therapy without surgery cannot cure the patient.
Palliative approach 
- Indication: patients with advanced or metastatic pancreatic cancer
- Chemotherapy regimens
- Pharmacotherapy: analgesia according to the WHO step-by-step plan
- Radiotherapy: used in patients with symptomatic metastasis, especially to the brain and bones (rare)
- Celiac ganglion block (celiac plexus block): when pain management according to the WHO step-by-step plan fails
Management of gastrointestinal complications
Percutaneous transhepatic bile duct drainage (PTCD): if endoscopic access path is complicated (e.g., in duodenal stenosis, duodenal resection, and inaccessibility of the biliodigestive anastomosis)
- Initially, external drainage in a collection bag
- May be changed into an internal drainage over time by using specific drainage systems and Bougies.
- Percutaneous transhepatic bile duct drainage (PTCD): if endoscopic access path is complicated (e.g., in duodenal stenosis, duodenal resection, and inaccessibility of the biliodigestive anastomosis)
- Gastric outlet stenosis: gastroenterostomy
- Ileus/subileus: percutaneous endoscopic gastrostomy (PEG) tube as a relief tube
- Cachexia: nutrition counseling
- Lymphogenic and hematogenous metastases: often already present at time of diagnosis
- Gastric outlet stenosis
- Stenosis of the common bile duct
- Other complications
We list the most important complications. The selection is not exhaustive.