Pancreatic Cancer - Symptoms

The symptoms of pancreatic cancer are polymorphic and largely depend on the location, type and size of the tumor, its relationship to nearby organs, duration of the disease (stage), presence or absence of metastases. The symptoms of the initial stage of pancreatic carcinoma are rather vague: weight loss, anorexia, dyspepsia, weakness, loss of ability to work; their frequency varies. More indicatively, none of these symptoms can be eliminated, and they gradually increase, new symptoms are added. Due to this "uncertainty" of symptoms, patients consult a doctor late, not earlier than 2-3 months after the appearance of the first signs of the disease (40%), and most - after 6 or even 12 months, on average after 4.5 months. Unfortunately, until relatively recently, methods for precise instrumental and laboratory diagnostics of this disease were also absent (ultrasound, CT, etc. were developed and became available only 20-15 years ago). Therefore, even with relatively early appeal of some patients for medical help (but with unclear clinical symptoms), doctors did not have the opportunity to conduct those studies that would allow them to confirm the presence of a pancreatic tumor if they suspected an oncological disease.

They had only indirect, uninformative methods at their disposal, such as, for example, determining by X-ray the increase in the distance between the spine and the stomach, signs of compression squeezing of the duodenum by the enlarged head of the pancreas (Frostberg's symptom), and an increase in ESR. In this regard, the stage of outpatient or hospital examination often required repeating the examinations and monitoring the patient over time and took a long time - sometimes several weeks or more. As a result, radical surgery could be performed only in 10-25% of patients. Nevertheless, in most cases, the most disturbing symptoms for patients and forcing them to see a doctor (but these are no longer early signs of this disease!) are pain in the upper half of the abdomen, anorexia, weight loss turning into cachexia, dyspeptic phenomena, general malaise, loss of strength, and an increase in temperature.

In the later period, patients almost always experience a complete loss of appetite, which can be called anorexia pancreatica. Both loss of appetite and exhaustion are early, constant and always progressive symptoms; significant weight loss (by 10-20 kg or more in 2-3 months) almost always occurs with this type of cancer. Dyspeptic symptoms ( nausea, vomiting, diarrhea ) are common, which are inevitable with lesions of the digestive tract; steatorrhea and creatorrhea, which occur in 10-15% of cases, deserve attention. Severe fever is rarely observed.

Abdominal pain in pancreatic cancer is very common (70-80%); it has some peculiarities. In case of cancer of the head of the pancreas, pain is most often localized in the right hypochondrium, sometimes resembling pain in case of peptic ulcer, cholecystitis, attacks of cholelithiasis. Pain is dull, sometimes burning, severe in nature, felt in the depth of the abdomen (sometimes radiating to the right - in case of damage to the head or to the left - in case of cancer of the tail of the gland). Pain is usually not associated with food intake or with other circumstances and does not leave the patient either day or night (night pain). For cancer of the body and tail of the pancreas, pain is even more characteristic, often comes to the forefront as the earliest and leading symptom of the disease, often they are extremely painful, unbearable. Pain in this localization of cancer is observed in the epigastric region or left upper quadrant of the abdomen, often acquires a girdle-like character; in rarer cases they are localized in the lumbar region. The pains often radiate to the spine (lower thoracic and upper lumbar vertebrae), left shoulder blade, shoulder, and substernal region. These pains are associated with pressure or tumor growth on the nerve trunks of the celiac plexus located behind the pancreas, i.e. these are solar pains, often radiating to all areas of the abdomen. In the supine position the pains in many cases increase, which depends on the increased pressure of the tumor on the celiac plexus. Therefore, patients with pancreatic cancer often take a forced position: sitting, slightly bent forward, or lying on their stomach or side, with their legs bent; in these positions the pains are somewhat less intense, since the pressure of the pancreas and the viscera located in front of it, the anterior abdominal wall on the celiac and other nerve plexuses and nerve trunks decreases.

For cancer localized in the head of the pancreas, mechanical (subhepatic) jaundice with some enlargement of the liver and a positive Courvoisier symptom (palpable, painless gallbladder overstretched with bile) is characteristic due to compression and invasion of the common bile duct by the tumor or, less commonly, compression of the hepatic ducts by enlarged lymph nodes in the liver hilum due to tumor metastases. The appearance of jaundice is not preceded by an attack of cholelithiasis colic, it occurs gradually, imperceptible at first, until it attracts the attention of the patient and others. Once it occurs, jaundice quickly increases, while the patient's skin gradually acquires a greenish, greenish-gray or dark olive color (due to the conversion of bilirubin, which colors the skin and other tissues, into biliverdin); hyperbilirubinemia reaches 260-340 μmol/l (15-20 mg%) and higher. Due to the retention and accumulation of bile acids in the blood and tissues, a characteristic triad of symptoms occurs: severe skin itching, forcing patients to scratch the skin continuously, relative bradycardia, symptoms of CNS irritation (irritability, increased excitability, irascibility, sleep disorders, sometimes hallucinations). The feces become discolored, since bile does not enter the intestine, and have a clayey, gray-white color, and laboratory testing shows the absence of stercobilin in it. However, conjugated (direct) water-soluble bilirubin begins to be excreted in large quantities with urine, giving it a brown color (in the figurative expression of old authors, - "the color of dark beer") with bright yellow foam. Later, as a result of secondary damage (cholestatic hepatitis), symptoms of hemorrhagic diathesis and liver failure often appear.

Thus, focusing on this very important, visual and immediately attracting the attention of the patient, those around him, and the doctor diagnostic sign, it is possible to distinguish two main clinical forms - icteric and anicteric.

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Symptoms of Different Forms of Pancreatic Cancer

The icteric form of the disease, as already noted, is more typical for carcinoma of the head of the pancreas, compressing the common bile duct. However, with a small tumor and its location outside the bile duct, jaundice may not develop. On the other hand, a tumor of the body and tail of the gland can grow into the head and cause jaundice. Usually, even before the onset of jaundice, some decrease in the patient's body weight is already noted.

The anicteric form of adenocarcinoma is somewhat less common than the icteric form (from 10 to 40% - according to different authors), mainly when the tumor is localized in the body and tail of the pancreas. Some patients experience predominantly pain in the upper half of the abdomen during the day and at night, while others have persistent back pain, as mentioned above.

There is also a purely cachectic form of pancreatic cancer; in this case, the patient may not feel pain, lies on the bed exhausted, refuses food, and is indifferent to everything.

Very rare are cases with prevalence of expressed psychopathic symptoms even in the early stage ( depression, apathy or anxiety, delirium); sometimes such patients are initially admitted to a psychiatric hospital. Often some signs of depression precede other symptoms of this disease. The syndrome of higher nervous activity disorder, as well as inhibition of the food center, are attributed to one of the paraneoplastic reactions, the mechanism of which, unfortunately, has not yet been studied. Sometimes with pancreatic cancer there are signs of "pancreatic encephalopathy" - aggressiveness of the patient, alternation of excitement with depression, the appearance of visual and auditory hallucinations. In part, these psychogenic symptoms can also be caused by narcotic drugs that are administered to patients due to very severe cancer pain.

During objective examination, a tumor is sometimes palpated in the depths of the epigastric region, dense, immobile; in the last stage, a solid tumor mass is detected. Such a tumor conglomerate in itself does not allow for precise recognition of the original site of the lesion and its differentiation from extensive adhesions or developed tumors of neighboring organs - stomach, colon, gall bladder, etc. Even during laparotomy, there are great difficulties; in 9% of the patients we observed, cancer of the gland was not recognized after laparotomy; similar difficulties may also be experienced by the dissector before careful dissection and analysis of the tumor mass.

In jaundice, an enlarged liver is observed due to bile stasis, and the presence of a lumpy liver is evidence of metastasis. An enlarged pear-shaped gallbladder is often detected - Courvoisier's symptom (in 30-40% of cases and more); this symptom serves as a distinction between pancreatic cancer and cholelithiasis.

In case of cancer of the body and tail of the pancreas, in addition to excruciating pain, anorexia and weight loss as the main symptoms, thirst and polyuria (due to insular apparatus insufficiency - tumor invasion of pancreatic islets) may be observed; in some cases, the tumor can be palpated. Jaundice is not typical for these tumor localizations, and if it occurs, it occurs in the very latest stages of the process, when the tumor invades the entire or almost entire pancreas. However, as noted by many authors, thrombosis of the vessels of various organs often occurs, and in some cases - multiple thrombosis. In this case, very significant shifts are observed in the blood coagulation system, causing the possibility of developing disseminated intravascular coagulation syndrome (DIC syndrome), phlebothrombosis. The latter is especially often observed in cancer of the body of the pancreas (in 56.2% of patients). Migrating venous thromboses, mainly in the lower extremities, in the absence of other symptoms are "alarming" in relation to malignant tumors, primarily of the pancreas. It is assumed that tumor cells release thromboplastin, which in turn causes a compensatory increase in fibrinolysis. Thus, the mechanism of physiological hemostasis restores balance, but at a pathological level, which is easily disturbed by minor irritants. A distinctive feature of "cancerous phlebothrombosis" is its resistance to anticoagulant therapy.

Spontaneous bone fractures occur in some patients as a result of tumor metastasis to the bones.

Splenomegaly develops when a cancerous tumor invades the splenic or portal vein, or when it is compressed or thrombosed. Sometimes it is possible to hear vascular noise to the left above the navel as a manifestation of compression of the splenic artery by the tumor.

Venothrombosis and thromboembolism are quite common in pancreatic cancer. Ascites is a late manifestation of the tumor.

According to research, pancreatic cancer has a variety of paraneoplastic symptoms. In some cases, these nonspecific symptoms may precede the appearance of overt symptoms of pancreatic cancer.