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cated for lesions strictly limited to the head of the pancreas, periampullary zone, and duodenum (T1, N0, M0) Five-year survival rates are 20 25% in this group and as high as 40% in those with negative resection margins and without lymph node involvement Preoperative endoscopic decompression of an obstructed bile duct may not be necessary but is often achieved with a plastic stent or short metal stent The best surgical results are achieved at centers that specialize in the multidisciplinary treatment of pancreatic cancer Adjuvant or neoadjuvant chemotherapy with gemcitabine and fluorouracil, possibly combined with irradiation, appears to be of benefit When resection is not feasible, endoscopic stenting of the bile duct is performed to relieve jaundice A plastic stent is generally placed if the patient s anticipated survival is less than 6 months (or surgery is planned) A metal stent is preferred when anticipated survival is 6 months or greater Surgical biliary bypass may be considered in patients expected to survive at least 6 months Surgical duodenal bypass may be considered in patients in whom duodenal obstruction is expected to develop later; alternatively, endoscopic placement of a self-expandable duodenal stent may be feasible Chemoradiation may be used for palliation of unresectable cancer confined to the pancreas Chemotherapy has been disappointing in metastatic pancreatic cancer, although improved response rates have been reported with gemcitabine Novel small molecules, including fluoropyrimidines, nucleoside cytidine analogues, and topoisomerase inhibitors, are under study Celiac plexus nerve block or thoracoscopic splanchnicectomy may improve pain control Photodynamic therapy is under study Surgical resection is indicated for all mucinous cystic neoplasms, symptomatic serous cystadenomas, and cystic tumors that remain undefined after helical CT, endoscopic ultrasonography, and diagnostic aspiration In the absence of locally advanced disease, survival is higher than for adenocarcinoma Endoscopic resection or ablation, with temporary placement of a pancreatic duct stent, may be feasible for ampullary adenomas, but patients must be followed for recurrence.

Prostatic induration on digital rectal examination or elevation of PSA Most often asymptomatic Rarely: systemic symptoms (weight loss, bone pain)

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Prostatic cancer is the most common cancer detected in American men and the second leading cause of cancerrelated death In the United States in 2005, over 232,000 new cases of prostate cancer were diagnosed, and about 30,300 deaths resulted However, the clinical incidence of the disease does not match the prevalence noted at autopsy, where more than 40% of men over 50 years of age are found to have prostatic carcinoma Most such occult cancers are small and contained within the prostate gland Few are associated with regional or distant disease The incidence of prostatic cancer increases with age Whereas 30% of men aged 60 69 years will have the disease, autopsy incidence increases to 67% in men aged 80 89 years Although the prevalence of prostatic cancer in autopsy specimens around the world varies little, the clinical incidence is considerably different (high in North America and European countries, intermediate in South America, and low in the Far East), suggesting that environmental or dietary differences among populations may be important for prostatic cancer growth A 50-year-old American man has a lifetime risk of 40% for latent cancer, 16% for developing clinically apparent cancer, and a 29% risk of death due to prostatic cancer Blacks, men with a family history of prostatic cancer, and those with a history of high dietary fat intake are at increased risk for developing it

Carcinoma of the pancreas, especially in the body or tail, has a poor prognosis Reported 5-year survival rates range from 2% to 5% Lesions of the ampulla have a better prognosis, with reported 5-year survival rates of 20 40% after resection; jaundice and lymph node involvement are adverse prognostic factors In carefully selected patients, resection of cancer of the pancreatic head is feasible and results in reasonable survival In persons with a family history of pancreatic cancer, screening with helical CT and endoscopic ultrasonography should be considered beginning 10 years before the age at which pancreatic cancer was diagnosed in a family member For those patients whose disease progresses despite treatment, meticulous efforts at palliative care are essential (see 5)

Canto MI et al Screening for early pancreatic neoplasia in highrisk individuals: a prospective controlled study Clin Gastroenterol Hepatol 2006 Jun;4(6):766 81 [PMID: 16682259]

Prostate cancer may be manifested as focal nodules or areas of induration within the prostate at the time of digital rectal examination (DRE) However, a large number of prostate cancers are associated with palpably normal prostates and are detected on the basis of elevations in serum PSA Rarely, patients present with signs of urinary retention (palpable bladder) or neurologic symptoms as a result of epidural metastases and cord compression Obstructive voiding symptoms are most often due to benign prostatic hyperplasia, which occurs in the same age group However, large or locally extensive prostatic cancers can cause obstructive voiding symptoms Lymph node metastases can lead to lower extremity lymphedema As the axial skeleton is the most common site of metastases, patients may present with back pain or pathologic fractures

disseminated intravascular coagulation can occur in patients with advanced prostate cancers 3 Prostate biopsy Transrectal ultrasound-guided biopsy is the standard method for detection of prostate cancer The use of a spring-loaded, 18-gauge biopsy needle has allowed transrectal biopsy to be performed with little patient discomfort and low attendant morbidity Local anesthesia is commonly used and increases the tolerability of the procedure The specimen preserves glandular architecture and allows for accurate grading Transrectal ultrasound-guided biopsy specimens are taken from the apex, mid portion, and base of the prostate in men who have an abnormal DRE or an elevated serum PSA Extended-pattern biopsies, including a total of at least ten biopsies, are associated with improved cancer detection and risk stratification of patients with newly diagnosed disease Patients with abnormalities of the seminal vesicles can have guided biopsies of these structures performed to allow for detection of local tumor invasion

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