Pancreatic cancer physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatospleenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.
Physical Examination
- Physical examination of patients with pancreatic cancer is usually remarkable for: epigastric tenderness, jaundice, and palpable intra abdominal mass.
- The presence of left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) on physical examination is diagnostic of metastasis.
- The presence of ascites and a palpable, non tender gall bladder on physical examination is a common finding in pancreatic cancer patients.
Appearance of the Patient
Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatosplenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.
Vital Signs
- Regular pulse
- Normal blood pressure
- Normal body temperature
Skin
Skin findings are as follows: [1][2][3][4][5]
- Jaundice: Yellowish discoloration of skin, sclera
- Associated with palpable, non-tender and distended gallbladder at the right costal margin (Courvoisier's sign)[6]
- Excoriations of the skin from unrelenting pruritus
- Darkening of the urine
- Acholic stools
- Pallor ±
- Skin manifestations may include:
- Bullous pemphigoid
- Cicatricial pemphigoid
- Migratory superficial thrombophlebitis (classic Trousseau's syndrome)
- Pancreatic panniculitis:
- Associated with acinar cell variant of pancreatic cancer
- Located mostly on the legs
- Appears as an erythematous subcutaneous area of nodular fat necrosis
The following picture depicts bullous pemphigoid lesions in a patient:
{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}
Neck
- Signs of metastatic disease include: [7]
- Left supraclavicular lymphadenopathy (Virchow's node)
- Palpable periumbilical mass (Sister Mary Joseph's node)
- Metastatic palpable mass in the rectal pouch (Blumer's shelf)
- Involvement of other nodes in the cervical area
Abdomen
Abdominal examination is as follows: [8][9][10]
- Abdominal distention
- Abdominal tenderness:
- Site: tenderness in mid epigastric region
- Onset: insidious
- Character: gnawing, visceral quality
- Radiation- mid/lower back due to tumor invasion of the retroperitoneal splanchnic nerve plexus
- Relieving factors: relieved on lying down in a curled or fetal position may improve the pain
- Aggravating factors: worse on lying supine or eating
- Timing: intermittent
- Severity- mild-moderate, worse at night
- An abdominal mass may be palpable in the epigastrium.
- Hepatomegaly may arise from liver metastasis
- splenomegaly may arise from portal vein obstruction
- hepatosplenomegaly
- Fluid thrill and dullness to percussion may be present due to ascites
Genitourinary
- In advanced stages of pancreatic cancer, metastatic palpable mass may be present in the rectal pouch.(Blumer's shelf)
References
- ↑ Kalser MH, Barkin J, MacIntyre JM (1985). "Pancreatic cancer. Assessment of prognosis by clinical presentation". Cancer. 56 (2): 397–402. PMID 4005804.
- ↑ Khorana AA, Fine RL (2004). "Pancreatic cancer and thromboembolic disease". Lancet Oncol. 5 (11): 655–63. doi:10.1016/S1470-2045(04)01606-7. PMID 15522652.
- ↑ Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G (1986). "Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center". J. Clin. Oncol. 4 (4): 509–14. doi:10.1200/JCO.1986.4.4.509. PMID 3958764.
- ↑ Ostlere LS, Branfoot AC, Staughton RC (1992). "Cicatricial pemphigoid and carcinoma of the pancreas". Clin. Exp. Dermatol. 17 (1): 67–8. PMID 1330387.
- ↑ Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T (1988). "Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients". Cancer. 62 (1): 135–41. PMID 3164230.
- ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
- ↑ Galvañ VG (1998). "Sister Mary Joseph's nodule". Ann. Intern. Med. 128 (5): 410. PMID 9490607.
- ↑ Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T (1996). "Clinicopathologic features of small pancreatic adenocarcinoma. A collective study". Cancer. 78 (5): 986–90. doi:10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A. PMID 8780535.
- ↑ Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R (1986). "Collective review of small carcinomas of the pancreas". Ann. Surg. 203 (1): 77–81. PMC 1251042. PMID 3942423.
- ↑ Mujica VR, Barkin JS, Go VL (2000). "Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants". Pancreas. 21 (4): 329–32. PMID 11075985.