In an age of impressive and ever-improving medical technology, the basic physical exam findings of many diseases have taken a back seat to the more expensive diagnostic and laboratory tests, such as CT scans, MRIs, or biomarkers. Numerous factors may explain this paradigm shift, including decreased time with patients, reimbursement by insurance companies, and medical-legal issues.
Prior to any physical exam or diagnostic studies, obtaining a thorough medical history continues to be a mainstay when evaluating a patient for cancer. This is especially true for patients with signs and symptoms which may be indicative of pancreatic cancer. These patients should be asked about family and social history, unintentional weight loss, jaundice, increased urine pigmentation, clay-colored stools, new “lumps or bumps” they may have noticed (especially on the abdomen), and any abdominal or back pain they might be experiencing. Even before extensive tests are performed, information derived from the family history, physical exam, and symptoms can point a physician toward a diagnosis of pancreatic cancer..
Many physicians develop their own examination style throughout their career; however, a traditional physical exam looks at the entire body in a systematic, yet focused, fashion, since a combination of symptoms can help pinpoint or rule out some illnesses. With regards to pancreatic cancer, some of the most obvious findings related to this cancer type can be found on the skin. Aside from the traditional jaundice, patients with pancreatic cancer can sometimes have newly developed acanthosis nigricans, which is a poorly delineated, hyperpigmentation of the skin that often feels velvety and is typically found on the neck, axilla, abdomen, and groin. This symptom is also common in patients with diabetes, thus it would be less concerning if a patient had medical history of long-standing or poorly controlled diabetes.
Another dermatologic symptom that may indicate pancreatic cancer is Trousseau syndrome[TD1] —a migratory, superficial thrombophlebitis secondary to the hypercoaguable state induced by the pancreatic cancer. This hypercoaguable state also can lead to an increased risk of deep vein thrombosis, which may result in a “palpable cord” in the calf, visible erythema of the lower extremity, or a positive Homan’s sign (calf pain upon dorsiflexion of the foot at the ankle). Complications associated with thromboses also appear to be more common in pancreatic cancers originating in the body and tail regions.
In addition to signs of pancreatic cancer noted by a thorough skin examination, signs of metastatic disease, in particular, can involve several lymph nodes. A Virchow node, located in the left supraclavicular region, can be both enlarged and solid in a patient with metastatic pancreatic cancer. This node is enlarged secondary to the lymphatic drainage from the abdominal cavity, which empties into the left subclavian vein. An enlarged periumbilical lymph node, called Sister Mary Joseph node, can also indicate metastatic spread of pancreatic cancer.
When examining the abdomen, an epigastric mass may or may not be palpable depending on the size of the mass and the patient’s body type. Courvoisier sign indicates a non-tender, palpable gallbladder in the right upper quadrant. This is a result of the pancreatic mass obstructing the biliary system and causing a back-up, which leads to abdominal distention. On physical exam, patients with metastatic pancreatic cancer may also have ascites, which can be identified with a positive fluid wave or shifting dullness to percussion.
Time spent with patients is becoming increasingly limited, and the impact the impending healthcare reform may have on this time remains to be seen. Regardless, it is always important to keep key parts of the physical examination in mind when evaluating a patient for pancreatic cancer.