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Pancreas CANCER Home / Pancreas Cancer

Awareness

The pancreas is a gland located behind the stomach and in front of the spine. The gland lies transversely (horizontally) across the upper abdomen in close proximity to the small intestine (duodenum), bile duct and spleen, in its various aspects. Important blood vessels – portal vein m hepatic artery, splenic artery and the superior mesenteric vessels , lie in intimate proximity to the gland and need to be carefully dissected and preserved during pancreatic surgery, hence making pancreatic surgery very delicate and complex. The pancreas produces digestive juices and hormones that regulate blood sugar. Cells called exocrine pancreas cells produce the digestive juices, while cells called endocrine pancreas cells produce the hormones. The majority of pancreatic cancers start in the exocrine cells.

Some Facts about pancreatic cancers

  • 10th Most Common Cancer In The United States
  • 7th Most Frequent Cancer In Europe
  • 4th Leading Cause Of Cancer Associated Mortality
  • 2.8% Cancer In Men And 3.2% Cancer In Women
  • Overall Incidence : 11.6 /100000 In Men And 8.1/100000 Women
  • 66% ( 2/3rd ) present with locally advanced or metastatic disease at presentation
  • 15-20% present with a potentially resectable tumour - meaning an early tumour which can be successfully treated with major surgery

Important Facts

  • Development of new onset diabetes in any person > 50 years of age or sudden worsening of pre-existing diabetes, may be an indication of an underlying pancreas tumour and should not be ignored
  • Acute pancreatitis can be the first signal of a pancreas cancer.

Risk Factors For Pancreas Cancer

The factors which could put you at risk for developing pancreatic cancer include

  • Smoking
  • Chronic pancreatitis (inflammation of the pancreas)
  • Inherited conditions (including hereditary pancreatitis)
  • Familial pancreatic cancer syndromes
  • Long-standing diabetes
  • Obesity
  • Symptoms
  • Prevention
  • Diagnosis
  • Treatment
  • Nonspecific abdominal pain : imaging
  • Upper abdominal pain / discomfort / nausea / vomiting / dyspepsia/ anorexia/ weight loss
  • Jaundice **
  • Pancreatitis
  • New onset diabetes***
  • Worsening of pre-existing diabetes***
  • New onset thrombo embolic phenomena – developments of blood clots elsewhere in the body , without obvious reason
  • Chronic pancreatitis : pre – existing
  • Detection of pancreatic cysts : IPMN , MCN on imaging – these are cysts ( fluid filled cavities ) within the pancreas , which may be cause of abdominal symptoms ( pain, discomfort, etc ) or may be a chance (incidental ) finding on an imaging study done for any reason. Not all cysts are malignant – some cysts are potentially malignant and may need further investigations to define their exact nature, malignant potential and may need treatment accordingly.

Chemotherapy

May be given

Surgery for pancreas cancer can broadly be defined into three types

  • After surgery : adjuvant chemotherapy – to achieve complete control of disease and prevent recurrence
  • Before surgery : neo adjuvant chemotherapy : to downstage the disease and reduce the size of the tumour, to facilitate and allow for definitive surgery
  • Palliative chemotherapy : when curative surgery is not possible and hence chemotherapy allows only for disease control / palliation

Radiation
May be given

Surgery for pancreas cancer can broadly be defined into three types

  • In select cases before surgery in Borderline resectable pancreas cancer, to facilitate and downstage tumours
  • Sometimes after surgery – adjuvant radiation
  • Palliation of pancreas cancer when unresectable / metastatic disease

Neuroendocrine tumours of the pancreas

There is a small subgroup of pancreas tumours which are Neuro endocrine tumours (NET). These arise from the hormone producing cells within the pancreas. They are of a relatively slow growing nature and relatively benign. Although may exhibit malignant potential (high grade- neuroendocrine carcinomas).

Hormone secreting NET, may produce hormonal syndromes depending on the hormone secreted and can be insulinomas, glucagunomas, gastrinomas and other rare lesions. These account for < 10% of all NET of the pancreas.

Treatment essentially depends on the same lines as pancreatic cancers and will generally involve surgery.

Apart from a detailed clinical history, physical examination and blood tests, some advanced radiological imaging is required for diagnosis of pancreatic tumours

  • Blood tests: tumour marker: Ca 19-9: this is a helpful blood test, helping in diagnosis of pancreas cancer. The levels of Ca 19-9 are increased in pancreas cancer. False (non-cancer related elevations) of the same may also happen due to some other disease conditions and in jaundice due to other reasons. Ca 19-9 levels can be used to monitor / follow up patients after their pancreas cancer treatment / surgery and serves as a good indication cancer recurrence. Values of Ca 19-9 should be interpreted in consultation with your treating physician.
  • CT scan (computed tomography) - A good quality CT scan is the cornerstone of diagnosis. CT scan also very accurately depicts the precise location of the pancreas tumour and defines its relationship to the adjacent organs including the blood vessels, helping therefore to define and stage the disease accurately, which has implications on choosing the right treatment
  • MRI (magnetic resonance imaging) – helps as an additional investigation
  • Endoscopic ultrasound (EUS) – this investigation is performed via endoscopy and accurately looks deeper into the pancreas. It helps in taking biopsies (tissue samples) as well which can help establish the diagnosis of tumour / cancer. In some difficult cases, it can help differentiate between tumour and inflammation (which can mimic tumour). In cystic lesions of the pancreas, EUS can help aspirate cyst fluid and send the same for analysis.
  • Endoscopic retrograde cholangiopancreatography (ERCP) – this procedure may be required in select cases of pancreas tumours. ERCP done via endoscopy, is a modality to insert a stent (tube), within the bile ducts and help reduce jaundice and infection arising due to the same. It’s advised by your consulting physician based on the patient’s clinical condition. In some cases of pancreas tumour associated with deep jaundice ( yellowing of skin ) and/ or associated infection ( cholangitis ), ERCP with biliary stenting ( insertion of either a metal or plastic tube ) may be required to control the infection and facilitate subsequent surgery to remove the pancreas tumour .
  • Percutaneous transhepatic cholangiography (PTC; procedure used to X-ray liver and bile ducts) – this is another procedure used to reduce the jaundice – it consists of a tube / stent, inserted under local anaesthesia through the bile tubes in the liver. It’s done to reduce the jaundice and control the infection where indicated and if for some reason ERCP can’t be done or has not been successful.
  • Biopsy (removal of tissue to view it under a microscope) – biopsy of the tumour may be done at time of endoscopy, ERCP or EUS. It can also be done under CT or Ultrasound guidance. While biopsy helps achieve the diagnosis of cancer, it’s not always required. Getting a pancreatic biopsy is not always easy since the pancreas is a difficult organ to access. Needing a biopsy or not can be defined by your treating physician/ oncology physician.

Surgery – removal of the part of the pancreas bearing the tumour, with adequate margin (surrounding tissue) is the only definitive and potentially curative treatment for pancreatic cancer. Unfortunately majority of patients present at later stages and only about 15-20% of all patients with pancreas cancer, are eligible for surgery at presentation.

Surgery for pancreas cancer can broadly be defined into three types

  • Pancreatico duodenctomy: this is for tumours, largely located within the head / uncinate process, (right side of the pancreas gland).
  • Distal Pancreatectomy / with or without removal of the spleen : for tumours located in the body or tail of the pancreas : left side of the pancreas
  • Sub-total / Total pancreatectomy: this may be required occasionally (although not very often), for multifocal tumours / certain cystic lesions within the pancreas gland (IPMN) or if pancreatico duodenectomy is not feasible.
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