Definition

A malignant tumor originating from the parenchymal cells of the pancreas. Approximately 90% are ductal adenocarcinomas, with the remainder including pancreatic neuroendocrine tumors, cystadenocarcinomas, acinar cell carcinomas, among others. It is typically characterized by rapid growth, an asymptomatic early stage, and a propensity to invade adjacent blood vessels and lymph nodes. Diagnosis often occurs at an advanced stage, leading to a very poor prognosis.

Pancreatic Cancer Staging

Primary Tumor (pT)

pTx: Cannot be assessed.

pT0: No evidence of primary tumor.

pTis: Carcinoma in situ, including high-grade pancreatic intraepithelial neoplasia (PanIN-3), intraductal papillary mucinous neoplasm with high-grade dysplasia, intraductal tubulopapillary neoplasm with high-grade dysplasia, and mucinous cystic neoplasm with high-grade dysplasia.

pT1: Tumor maximum diameter ≤ 2 cm.

    pT1a: Tumor maximum diameter ≤ 0.5 cm.

    pT1b: Tumor maximum diameter > 0.5 cm but ≤ 1 cm.

    pT1c: Tumor maximum diameter > 1 cm but ≤ 2 cm.

pT2: Tumor maximum diameter > 2 cm but ≤ 4 cm.

pT3: Tumor maximum diameter > 4 cm.

pT4: Tumor of any size involving the celiac axis, superior mesenteric artery, or common hepatic artery.

Regional Lymph Nodes (pN)

pNx: Cannot be assessed.

pN0: No regional lymph node metastasis.

pN1: Metastasis in 1 to 3 regional lymph nodes.

pN2: Metastasis in 4 or more regional lymph nodes.

Distant Metastasis (pM)

pMx: Cannot be assessed.

pM0: No distant metastasis.

pM1: Distant metastasis present.

Pancreatic Cancer TNM Staging

Stage 0: Tis N0 M0

Stage IA: T1 N0 M0

Stage IB: T2 N0 M0

Stage IIA: T3 N0 M0

Stage IIB: T1, T2, T3 N1 M0

Stage III: T1, T2, T3 N2 M0; T4 Any N M0

Stage IV: Any T Any N M1

Common Symptoms

1.Abdominal Discomfort or Pain: This is a common initial symptom. Most patients experience only upper abdominal discomfort, dull pain, or bloating, which can be easily confused with gastrointestinal or hepatobiliary diseases. Pain may worsen after meals if there is obstruction of the pancreatic duct. In advanced stages, tumor invasion of the celiac plexus can cause persistent severe pain.

2.Weight Loss and Fatigue: 80–90% of patients experience weight loss, fatigue, and reduced energy early in the disease, related to loss of appetite, anxiety, and tumor consumption.

3.Digestive Symptoms: When the tumor blocks the distal common bile duct and pancreatic duct, preventing bile and pancreatic juices from entering the duodenum, indigestion often occurs. Impaired pancreatic exocrine function may lead to diarrhea. Advanced tumors invading the duodenum can cause intestinal obstruction or bleeding.

4.Jaundice: Related to bile duct obstruction, it is the most prominent clinical manifestation of pancreatic head cancer, often accompanied by itchy skin, dark tea-colored urine, and clay-colored stools.

5.Other Symptoms: Some patients may experience persistent or intermittent low-grade fever, usually without biliary infection. Some may also develop abnormal blood sugar levels.

Prevalence

Global new cases in 2022: ≈ 509,000

Global deaths in 2022: ≈ 466,000

Risk Factors

Non-modifiable Factors:

Age: Median age at diagnosis is about 71 years; 85% of cases are ≥65 years old.

Sex: Incidence in males is about 1.3–1.5 times that in females.

Family History and Genetic Syndromes: About 10% are familial; carriers of mutations in genes such as BRCA1/2, CDKN2A, PALB2, or those with Peutz–Jeghers syndrome, Lynch syndrome have a 3.5–10 times higher risk.

Modifiable or Environmental Exposure Factors:

Smoking: Smokers have at least double the risk, accounting for about 20% of cases; risk approaches that of non-smokers only 20 years after quitting.

Alcohol: Consuming ≥3 alcohol units daily (approx. 1 large glass of wine) combined with smoking significantly increases risk; heavy drinking can further elevate risk by inducing chronic pancreatitis.

Obesity and Metabolism: High body mass index and abdominal obesity can increase risk by over 10%; type 2 diabetes is also an independent risk factor.

Diet: Diets high in saturated fat, red and processed meats (ham, bacon, sausage), and sugary drinks promote inflammation, increasing the risk of both incidence and death; anti-inflammatory diets (rich in vegetables, whole grains, oily fish) offer relative protection.

Chronic Pancreatitis: Long-term inflammation from any cause (alcoholic, hereditary, idiopathic) promotes carcinogenesis through repeated DNA damage and defective repair.

Chemical Exposure: Occupational exposure to industrial chemicals such as chlorinated hydrocarbons, benzene, asbestos, pesticides, and heavy metals increases risk in populations like dry cleaners, metalworkers, and agricultural workers.

Diagnosis of Pancreatic Cancer

The modern diagnosis of pancreatic cancer is a systematic process integrating clinical evaluation, imaging, pathology, and molecular biology. The core pathway begins with an initial assessment of the patient's symptoms (such as jaundice, abdominal pain, weight loss) and serum tumor markers (primarily CA19-9). Contrast-enhanced CT (particularly thin-slice multiphase pancreatic protocol) is then employed as the primary imaging method for tumor localization, evaluation of its relationship with surrounding vessels, and initial assessment of resectability. Magnetic Resonance Imaging (MRI/MRCP) is often used as an important supplement to clarify pancreaticobiliary duct structures and liver condition. Definitive diagnosis relies on pathological evidence, typically obtained through tissue acquired via Endoscopic Ultrasound (EUS)-guided Fine-Needle Aspiration (FNA), a technique particularly advantageous for detecting small lesions. In the era of precision medicine, guidelines strongly recommend molecular pathological testing for diagnosed patients. Routine tests include, but are not limited to, assessing Homologous Recombination Deficiency (HRD) status by detecting genes like BRCA1/2, as well as screening for genetic variations such as Microsatellite Instability (MSI)/Mismatch Repair Deficiency (dMMR), KRAS, NRG1, NTRK, aiming to identify opportunities for targeted and immunotherapy. For staging, PET-CT holds unique value in detecting distant occult metastases. Finally, all diagnostic information is consolidated for review by a Multidisciplinary Team (MDT), involving experts from surgery, medical oncology, radiology, and pathology. The team jointly determines the TNM stage, resectability classification (resectable/borderline resectable/unresectable), and formulates an individualized comprehensive treatment plan.

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Follow-up Management

Follow-up and survivorship management for pancreatic cancer is a systematic, long-term process integrating regular medical monitoring, proactive symptom control, psychosocial support, and precision maintenance therapy. For patients who have undergone curative treatment, guidelines recommend clinical follow-ups every 3–6 months for the first 2 years post-treatment. These check-ups include serum tumor markers (e.g., CA19-9) and imaging studies (e.g., contrast-enhanced CT) to monitor for recurrence, with intervals gradually lengthening thereafter. For patients with advanced disease, the management focus shifts towards providing optimal supportive care through a multidisciplinary team. This includes professional nutritional support, pain management, psychological counseling, and palliative care aimed at maintaining quality of life, which is crucial for preserving patients' performance status and ensuring treatment continuity. Furthermore, based on molecular pathological test results obtained during treatment (e.g., BRCA, NTRK gene status), providing corresponding targeted drugs and other precision maintenance therapies for eligible patients has become a new strategy for improving survival.