Diagnosis of Endocrine pancreatic cancer
Endocrine pancreatic cancer Diagnosis: Book Excerpts
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Diabetes mellitus:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
According to the American Diabetes Association (ADA), DM can be diagnosed if any of the following exist:
❑ symptoms of diabetes (polyuria, polydipsia, and unexplained weight loss) plus a random (non-fasting) blood glucose level greater than or equal to 200 mg/dl accompanied by symptoms of diabetes.
❑ a fasting blood glucose level (no caloric intake for at least 8 hours) greater than or equal to 126 mg/dl.
❑ a plasma glucose value in the 2-hour sample of the oral glucose tolerance test greater than or equal to 200 mg/dl. This test should be performed after a glucose load dose of 75 g of anhydrous glucose.
If results are questionable, the diagnosis should be confirmed by a repeat test on a different day. The ADA also recommends the following testing guidelines:
❑ Test every 3 years: people age 45 or older without symptoms
❑ Test immediately: people with the classic symptoms
❑ High-risk groups should be tested frequently: Individuals with impaired glucose tolerance usually have normal blood levels unless challenged by a glucose load, such as a piece of pie or glass of orange juice. Two hours after a glucose load, the glucose level ranges from 140 to 199 mg/dl. These individuals have an abnormal fasting glucose level between 110 and 125 mg/dl. Because the fasting plasma glucose test is sufficient to make the diagnosis of diabetes, it replaces the oral glucose tolerance test. (See Classifying blood glucose levels.)
An ophthalmologic examination may show diabetic retinopathy. Other diagnostic and monitoring tests include urinalysis for acetone and blood testing for glycosylated hemoglobin (Hb A1C), which reflects recent glucose cortisol.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Introduction: Malignant Neoplasms:
Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))
A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).
An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:
❑as a baseline during chemotherapy to evaluate the extent of tumor spread
❑to regulate drug dosage
❑to prognosticate after surgery or radiation
❑to detect tumor recurrence.
Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Malignant spinal neoplasms:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.
❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Computed tomography scan shows cord compression and tumor location.
❑ Frozen section biopsy at surgery identifies the tissue type.
❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Multiple endocrine neoplasia:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Investigating symptoms of pituitary tumor, hypoglycemia, hypercalcemia, or GI hemorrhage may lead to a diagnosis of MEN. Diagnostic tests must be used to carefully evaluate each affected endocrine gland. For example, radioimmunoassay showing increased levels of gastrin in patients with peptic ulceration and Zollinger-Ellison syndrome suggests the need for follow-up studies for MEN I because 50% of patients with Zollinger-Ellison syndrome have MEN. After confirmation of MEN, family members must also be assessed for this inherited syndrome.
Magnetic resonance imaging or computed tomography scan of the abdomen may show pancreatic tumor. Insulin test may show increased levels and fasting blood sugar may be low.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pancreatic cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Definitive diagnosis requires a laparotomy with a biopsy.
Other tests used to detect pancreatic cancer include:
❑ultrasound of the abdomen — can identify a mass but not its histology
❑computed tomography scan of the abdomen — similar to ultrasound but shows greater detail
❑ angiography — shows vascular supply of tumor
❑ endoscopic retrograde cholangiopancreatography — allows visualization, instillation of contrast medium, and specimen biopsy
❑ magnetic resonance imaging of the abdomen — shows tumor size and location in great detail.
Laboratory tests supporting this diagnosis include serum bilirubin (increased); serum amylase and serum lipase (sometimes elevated); prothrombin time (prolonged); aspartate aminotransferase and alanine aminotransferase (elevations indicate necrosis of liver cells); alkaline phosphatase (marked elevation occurs with biliary obstruction); plasma insulin immunoassay (shows measurable serum insulin in the presence of islet cell tumors) (see Islet cell tumors); hemoglobin (Hb) and hematocrit (HCT) (may show mild anemia); fasting blood glucose (may indicate hypoglycemia or hyperglycemia); and stools (occult blood may signal ulceration in GI tract or ampulla of Vater).
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetes Mellitus:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The initial presentation of DM can vary. Either type may present with the insidious onset of the symptoms associated with hyperglycemia (polyuria, polydipsia, and polyphagia) or with the abrupt onset of an acute complication [diabetic ketoacidosis (in type 1 DM) or nonketotic hyperglycemic-hyperosmolar coma (in type 2 DM)].
A. Type 1 diabetes. Patients with type 1 DM typically present before the age of 18 years. The symptoms heralding the disease emerge gradually as hyperglycemia appears and becomes more frequent and profound. Physiologic stress (e.g., an acute illness or trauma), which increases the requirement for insulin, can unmask the insulinopenia and give the impression that the problem is acute. Enuresis may be a clue for polyuria in a child who was previously toilet-trained. Lethargy, weakness, and weight loss are other common features.
B. Type 2 diabetes. Patients with type 2 DM usually present after the age of 40 years. The diagnosis is often made in an asymptomatic patient as a result of routine blood tests that reveal an elevation of plasma glucose. Other patients may present with the symptoms of hyperglycemia. The patient may have a history of recurrent skin infections or persistent vulvovaginitis. Other common symptoms include altered sensations in the extremities, nocturia, erectile dysfunction, and visual disturbances (Chapters 4.6, 5.1, 10.3, and 10.4). The use of glucocorticoids, β-adrenergic agonists, or thiazides can precipitate the symptoms of type 2 DM.
Physical examination
Patients often present with similar physical findings in both type 1 and type 2 DM, owing to hyperglycemia. In the young child, failure to grow and gain weight can occur with type 1 DM. The child may be ill appearing, lethargic, and often have signs of dehydration (tachypnea, tachycardia, and low blood pressure). Ketone production will produce a fruity odor on the patient’s breath. The patient with type 2 DM tends to be obese (especially upper body obesity) and may appear fatigued and have muscle weakness or decreased vision. The neurologic examination may reveal painful feet and numbness. Monilial infections may be found in the vagina and pubic areas.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Diabetes mellitus:
Diagnosis
(Handbook of Diseases)
In nonpregnant adults, diabetes mellitus is diagnosed with:
❑ at least two occasions of a fasting plasma glucose level greater than or equal to 126 mg/dl
❑ typical symptoms of uncontrolled diabetes and a random blood glucose level greater than or equal to 200 mg/dl
❑ a blood glucose level greater than or equal to 200 mg/dl at 2 hours after ingestion of 75 grams of oral dextrose.
Two tests are required for diagnosis; they can be the same two tests or any combination and may be separated by more than 24 hours.
An ophthalmologic examination may show diabetic retinopathy. Other diagnostic and monitoring tests include urinalysis for acetone and blood testing for glycosylated hemoglobin, which reflects glucose control over the past 2 to 3 months.
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Source: Handbook of Diseases, 2003
Pancreatic cancer:
Diagnosis
(Handbook of Diseases)
Definitive diagnosis requires a laparotomy with a biopsy. Other tests used to detect pancreatic cancer include:
❑ ultrasound — can identify a mass but not its histology
❑ computed tomography scan — similar to ultrasound but shows greater detail
❑ angiography — shows vascular supply of tumor
❑ endoscopic retrograde cholangiopancreatography — allows visualization, instillation of contrast medium, and specimen biopsy
❑ magnetic resonance imaging — shows tumor size and location in great detail.
Laboratory tests that can help support this diagnosis include serum bilirubin level (increased), serum amylase and serum lipase levels (sometimes elevated), prothrombin time (prolonged), and aspartate aminotransferase and alanine aminotransferase levels (elevations indicate necrosis of liver cells).
Additional pertinent studies include alkaline phosphatase level (marked elevation occurs with biliary obstruction), plasma insulin immunoassay (shows measurable serum insulin in the presence of islet cell tumors), hemoglobin level and hematocrit (may show mild anemia), fasting blood glucose level (may indicate hypoglycemia or hyperglycemia), and stool analysis (occult blood may signal ulceration in the GI tract or ampulla of Vater).
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Source: Handbook of Diseases, 2003
Pancreatitis:
Diagnosis
(Handbook of Diseases)
Clinical presentation and combined laboratory and radiographic findings form the basis for diagnosis. A thorough patient history (especially for alcoholism) and physical examination are the first steps in diagnosis; however, the retroperitoneal position of the pancreas makes physical assessment difficult.
Dramatically elevated serum amylase levels —in many patients over 500 U/L — confirm pancreatitis and rule out perforated peptic ulcer, acute cholecystitis, appendicitis, and bowel infarction or obstruction. Persistent elevation of serum amylase levels may indicate pancreatic necrosis, pseudocyst, or abscess.
Similarly, dramatically elevated amylase levels are also found in urine, ascites, or pleural fluid. Characteristically, amylase levels return to normal within 48 hours after the onset of pancreatitis, despite continuing symptoms. Laboratory values that support the diagnosis include:
❑ increased serum lipase levels, which rise more slowly than serum amylase levels
❑ white blood cell counts that range from 8,000 to 20,000/µl, with increased polymorphonuclear leukocyte counts
❑ elevated glucose levels — as high as 500 to 900 mg/dl — indicating hyperglycemia.
An abdominal computed tomography scan with contrast is the most sensitive noninvasive test used to confirm the diagnosis of pancreatitis; however, abdominal ultrasound and abdominal magnetic resonance imaging also show pancreatic inflammation. Other tests that may show alterations include aspartate aminotransferase, carcinoembryonic antigen, fecal fat test, ionized calcium, lactate dehyrogenase (LD), LD isoenzymes, serum magnesium, and trypsinogen.
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Source: Handbook of Diseases, 2003
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