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Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection

https://doi.org/10.1016/j.bpg.2010.02.007Get rights and content

Acute pancreatitis, chronic pancreatitis and pancreatic cancer are responsible for most of the burden of exocrine pancreatic disease. Glandular damage from recurrent bouts of acute pancreatitis can lead to irreversible changes characteristic of chronic pancreatitis. In recent decades accumulating evidence has defined longstanding pre-existing chronic pancreatitis as a strong risk factor for pancreatic cancer. The lag period between diagnosis of chronic pancreatitis and pancreatic cancer is usually one or two decades: pancreatitis appearing a year or two before the diagnosis of pancreatic cancer is often the result of tumour-related ductal obstruction. The risk of developing pancreatic cancer appears to be highest in rare types of pancreatitis with an early onset, such as hereditary pancreatitis and tropical pancreatitis. Even though there is a strong link between chronic pancreatitis and pancreatic cancer, over a 20 year period only around five percent of patients with chronic pancreatitis will develop pancreatic cancer. Until the development of more sophisticated screening procedures, screening is not recommended for patients with chronic pancreatitis.

Introduction

Located in the retroperitoneal space—the least accessible part of the abdomen—the pancreas is a robust gastrointestinal organ. In most individuals, the exocrine portion of the gland functions quietly and effectively, aiding in the digestion of approximately 25,000 kg of ingested food during an average lifetime. It has a considerable reserve capacity, so that functional inadequacy of the gland is not clinically recognizable unless most of the pancreas has been destroyed.

The exocrine portion of the gland is susceptible to three main illnesses: acute pancreatitis, chronic pancreatitis and pancreatic cancer. Acute pancreatitis, especially when caused by gallstones, is common, but chronic pancreatitis is a comparatively rare digestive tract disorder. In this report we will review the evidence linking chronic pancreatitis and pancreatic cancer, assess the frequency of development of malignancy in the course of pancreatitis, outline possible mechanisms involved in the transformation from a benign to a malignant pancreatic disorder, and review strategies for early detection.

Section snippets

Malignant transformation following benign disease

About 150 years ago Rudolf Virchow, an astute German pathologist, after observing white blood cells within tumour tissue, suggested that benign, inflammatory processes sometimes led to cancer [1]. Since then, numerous reports in many different organ systems have confirmed Virchow's suggestion [2]. For example parasitic disease, such as schistosomiasis causes bladder cancer; a bacterial disease, H. pylori causes gastric cancer; viruses (papillomvirus, hepatitis B and C) can cause cervical or

Incidence of chronic pancreatitis and pancreatic cancer

It is difficult to estimate the incidence of chronic pancreatitis because: (1) it can easily be confused with recurrent acute pancreatitis; (2) diagnostic criteria vary from centre to centre; (3) unlike other gastrointestinal organs, biopsy or direct visualization is difficult. However approximate incidence rates, mostly estimated from hospital admission or discharge rates are about five to ten per 100,000 per year, with male rates exceeding female rates.

For pancreatic cancer incidence rates

Chronic pancreatitis and pancreatic cancer: a meta-analysis

In this section we review and summarize previously published reports linking chronic pancreatitis and pancreatic cancer.

Results

A description of the main characteristics of the 22 studies included in the meta-analysis is reported in Table2. Eleven case-control studies investigated the association between unspecified pancreatitis and pancreatic cancer, six cohort and one case-control studies evaluated chronic pancreatitis, three cohort studies hereditary pancreatitis and one Indian study tropical pancreatitis. Among the twelve case-control studies, five included hospital controls, four healthy controls and three both

Screening and early detection of pancreatic cancer in chronic pancreatitis

Should patients with chronic pancreatitis be screened for pancreatic cancer? The United States Preventive Task force [34] has clearly stated that screening the general population for pancreatic cancer by current modalities is not recommended. Inherited familial genetic disorders account for about 5–10% of patients with pancreatic cancer: even in this high group screening is controversial *[35], [36], *[37], [38]. For patients with chronic pancreatitis the only group that might possibly benefit

Summary

Persons with any form of chronic pancreatitis are at increased risk of developing pancreatic cancer—one of the major causes of cancer mortality. Patients with an early onset pancreatitis such as hereditary pancreatitis and tropical pancreatitis have rates of pancreatic cancer that are at least 50-fold greater than in the general population. Smoking is a risk factor for both pancreatitis and pancreatic cancer, emphasizing the importance of this life-style factor in the prevention of both

Conflict of interest

None.

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    Supported by grants from Solvay Pharmaceuticals, and the C.D. Smithers Foundation.

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