Pancreatic Cancer

■ Classic presentation: a smoker in the 40-80-year-old range who has lost weight and is jaundiced. Symptoms may include epigastric pain, migratory thrombophlebitis (Trousseau syndrome, which a ho may be seen with other visceral cancer), or a palpable, nontender gallbladder (Courvoisier's sign)

■ Epidemiology: males > females, diabetics > nondiabetics, blacks > whites n Surgery (Whipple procedure): rarely curative; the prognosis is dismal

■ Cell of origin: ductal epithelium

Islet cell tumors:

1. Insulinoma (beta cell tumor): most common islet cell tumor. Look for two-thirds of Whipple's triad: hypoglycemia (glucose < SO mg/dl) and central nervous system symptoms due to hypoglycemia (confusion, stupor, loss of consciousness). As the good doctor, you will provide the third part of Whipple's triad: give glucose to relieve symptoms. Ninety percent of insulinomas are benign and cured with resection, if possible. In your work-up, take history and check C-peptide first to make sure that the patient is not a diabetic who accidentally took too much insulin or a patient with factitious disorder. C-peptide is high with insulinoma, low with other conditions.

2. Gastrinoma: Zollinger-Ellison syndrome is gastrinoma plus acid hypersecretion and peptic ulcer disease (gastrin causes acid secretion). Peptic ulcers are often multiple and resistant to therapy; they may be in an unusual location (distal duodenum or jejunum). More than one-half are malignant.

3. Glucagonoma (alpha cell tumor): hyperglycemia with high glucagon level and migratory necrotizing skin erythema.

Ovarian cancer usually presents late with weight loss, pelvic mass, ascites, and/or bowel obstruction in a postmenopausal woman. Any ovarian enlargement in a postmenopausal woman is cancer until proved otherwise. In women of reproductive age, most ovarian enlargements are benign. Ultrasound is a good first test to evaluate an ovarian lesion.Treatment includes debnlk-ing surgery and chemotherapy; prognosis is usually poor. Most ovarian cancer arises from ovarian epithelium. Serous cystadenocarcinoma, the most common ovarian cancer, often has psammoma bodies on histopathology.

Germ cell tumors make good questions:

1. Teratoma/dermoid cyst: look for a description of the tumor to include skin, hair, and/or teeth/bone; may show up on x-ray.

2. Sertoli-Leydig cell tumor: causes virilization (hirsutism, receding hairline, deepening voice, clitoromegaly).

3. Granulosa/theca-cell tumor: causes feminization and precocious puberty.

Terms worth knowing:

* Meig's syndrome: ovarian fibroma, ascites, and right hydrothorax. ■ Krukenbergs tumor: stomach cancer with metastases to both ovaries.

Note: Oral contraceptives have been shown to reduce the incidence of ovarian cancer by 50%; they also reduce endometrial cancer.

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