Pancreatic Cancer

PANCREATIC CANCER

Pancreatic cancer is a disease in which abnormal cells appear in the tissue of the pancreas as a result of abnormally dividing cells out of control. in the pancreas.

The pancreas is made up of two different kinds of tissue with different functions: the exocrine pancreas, which secretes enzymes into the digestive tract, which help to break down fats and proteins, and the endocrine pancreas, which secretes glucagon and insulin into the bloodstream in order to control blood sugar levels. In most cases, pancreatic cancers develop in the exocrine pancreas in 85 % of the cases. About 75% of all exocrine pancreatic cancers occur within the head or neck of the pancreas, 15 to 20% in the body and 5 to 10% in the tail of the pancreas.

 

Anatomy of the pancreas. The pancreas has three parts: head, body, and tail. It is found in the abdomen near the stomach, intestines and other organs.

 

How frequent is pancreatic cancer?

According to the American Cancer Society, the estimated number of pancreatic cancer in the US for  2018 are:

  • About 55,440 people (29,200 men and 26,240 women) will be diagnosed with pancreatic cancer.
  • About 44,330 people (23,020 men and 21,310 women) will die of pancreatic cancer.

Pancreatic cancer accounts for about 3% of all cancers in the US and about 7% of all cancer deaths.

The average lifetime risk of pancreatic cancer for men is about 1 in 63. For women, the lifetime risk is about 1 in 65.

Worldwide, more than 337,000 people will be diagnosed, and more than 330,000 will die of the disease. The incidence of pancreatic cancer is rising, and some reports project that the number of new pancreatic cancer cases and pancreatic cancer deaths will more than double by 2030.

 

What is the risk for pancreatic cancer?

Risk factors for pancreatic cancer include the following:

  • Smoking
  • Obesity
  • Personal history of diabetes
  • Chronic pancreatitis
  • A family history of pancreatic cancer or pancreatitis
  • Certain hereditary conditions

 

What are the symptoms of pancreatic cancer?

    • Weakness–86%
    • Weight loss–85%
    • Anorexia normal appetite–83%
    • Abdominal pain–79%

 

  • Pain in the stomach area–71%
  • Dark urine–59%
  • Jaundice 56%
  • Nausea–51%
  • Back pain–49%
  • Diarrhea–44%
  • Vomiting 33%
  • Fatty stools–25%
  • Thrombophlebitis–3%

 

Signs of pancreatic  cancer

  • Jaundice or yellowing of the skin or eyes–55%
  • Large liver or hepatomegaly–39%
  • Right upper quadrant mass–50%
  • Body wasting known as  cachexia–30%
  • Nontender but palpable distended gallbladder of the right costal margin–13%
  • Mass in the gastric area referred as a lump in the stomach–9%
  • Abdominal fluid ascites–5%

 

What are the types of benign pancreatic tumors?

Most of these tumors are benign or if it not surgically removed, they could progress into cancerous tumors and sometimes they are referred to as premalignant pancreatic tumors. They are often diagnosed as an incidental finding during a routine exam for something not related to the tumor. The most common types are:

Serous cystic neoplasms are usually benign, and most do not need to be treated unless they grow large or cause symptoms.

Mucinous cystic neoplasms have cysts filled with a jelly-like substance called mucin. These tumors almost always occur in women; some of them can progress to cancer over time if not surgical removed.

Intraductal papillary mucinous neoplasms grow in the pancreatic ducts and could become cancer if not surgically treated.

Solid pseudopapillary neoplasms (SPNs) develop in young women. Even though these tumors tend to grow slowly, they can sometimes spread to other parts of the body, so they are best treated with surgery.

 

What are the types of pancreatic cancer?

This information is mainly in the most common type of cancer of the pancreas, also known as pancreatic adenocarcinoma. Other tumors such as Acinar cell carcinomas and pancreatoblastomas are very rare tumors. Cystic tumors of the pancreas such as intraductal papillary mucinous neoplasms (IPMNs), adenosquamous carcinomas, squamous cell carcinomas, signet ring cell carcinomas, undifferentiated carcinomas, Ampullary cancer and undifferentiated carcinomas with giant cells.are also not covered by this guide.

Pancreatic endocrine tumors (neuroendocrine tumors)

When the cells of the endocrine pancreas divide in an uncontrolled manner the form of Tumors of the endocrine pancreas (NET). These are uncommon, making up less than 5% of all pancreatic cancers. Pancreatic NETs can be benign (not cancer) or malignant (cancer). Benign and malignant tumors can look alike under a microscope, so it is not always clear if a pancreatic NET is really cancer.

There are many types of pancreatic NETs.

Functioning NETs: produce active functional hormones that are released into the blood and cause symptoms. Each one is named for the type of hormone the tumor cells make.

  • Gastrinomas come from cells that make gastrin. About half of gastrinomas are cancers.
  • Insulinomas come from cells that make insulin. Most insulinomas are benign (not cancer).
  • Glucagonomas come from cells that make glucagon. Most glucagonomas are cancers.
  • Somatostatinomas come from cells that make somatostatin. Most somatostatinomas are cancers.
  • VIPomas come from cells that make vasoactive intestinal peptide (VIP). Most VIPomas are cancers.
  • PPomas come from cells that make pancreatic polypeptide. Most PPomas are cancers.

Most functioning NETs are gastrinomas or insulinomas. The other types are rare.

Non-functioning NETs: nonfunctional tumors that do not cause symptoms. They are more likely to be cancer than are functioning tumors. Carcinoid tumors: These NETs are much more common in other parts of the digestive system, although rarely they can start in the pancreas. These tumors often make serotonin

The treatment and outlook for pancreatic NETs depend on the specific tumor type and stage. but the outlook is generally better than that of pancreatic exocrine cancers.

 

How is pancreatic cancer diagnosed?

Unfortunately, pancreatic cancer is a very difficult tumor to diagnose most instances it presents at an advanced stage. People usually expressed no symptoms until cancer has already advanced to late stages.

Tumor markers in the blood that are normally utilized as an early detection to his a carcinoembryonic antigen and a protein named CA 19–9; but these levels do not go up in a lot of patients with early pancreatic cancer.  If there is hereditary pancreatic cancer history then genetic testing mutations can be used as an earlier marker. For people in families at high risk of pancreatic cancer, newer tests for detecting early pancreatic cancer may help. One of these is called endoscopic ultrasound

Good medical evaluation is fundamental in diagnosing pancreatic cancer.  Any most cases the diagnosis involves multiple specialties like primary physicians, surgeons, oncologist, and gastroenterologist.

Routine blood test and imaging studies are done including:

 

Pancreatic Cancer

 

 What are the stages of pancreatic cancer?

These illustrations provide a good understanding of how pancreatic cancer is stage

 

Survival Rates

 

Pancreatic ductal adenocarcinoma (PDA), which accounts for more than 90% of pancreatic cancer cases, is highly lethal; for all stages combined, the 1- and 5-year relative survival rates are 27% and 7%, respectively, making it the only cancer with an overall 5-year survival rate in the single digits. Even for those people diagnosed with local disease, 5-year survival is only 27%. More than half of patients are diagnosed at a distant stage, for which 5-year survival is 2%.

How is pancreatic cancer treated?

Treatment of pancreatic cancer depends on several factors such as the stage of the disease, location of the tumor, the age and condition of the patient. It is a multidisciplinary approach to defined the best treatment options.  Treatment options include surgery, chemotherapy, and radiation.

The only curative treatment for pancreatic cancer is complete surgical resection. Unfortunately, fewer than 20% of patients are candidates for surgery, because pancreatic cancer is usually detected after it has spread. Cancers that cannot be treated with surgery are called “unresectable.” For those patients with localized disease and small cancers with no lymph node metastases and no extension beyond the capsule of the pancreas, complete surgical resection can yield 5-year survival rates of 18% to 24%. Approximately 80% of patients who undergo surgery eventually relapse and die from the disease, suggesting a need for effective strategies to eradicate minimal residual disease following surgery to prevent relapse.

A. Surgery

Surgery is generally considered as a cure if the tumor is confined to the pancreas. In inoperable cases, it is done only as a palliative option to keep the patient comfortable and free from pain.

Tumor of Head of Pancreas

For tumors involving the head, Whipple’s procedure is performed. The gallbladder and a part of the bile duct may also be removed. The remaining parts of the pancreas and small intestine are reconstructed to allow passage of food and digestion.

Tumor Body and Tail of Pancreas

Surgery to remove the affected part of the body or tail may be performed

B. Chemotherapy

  • Chemotherapy is the use of drugs to kill cancer cells. They may be administered orally or intravenously and singly or in combination.
  • Chemotherapy may be combined with radiation (chemoradiation) to treat locally invasive inoperable tumors of the pancreas.
  • Chemoradiation may also be tried after surgery to reduce the risk of recurrence.
  • In patients with inoperable and advanced metastatic disease, chemotherapy may be used alone or in combination with targeted drug therapy.

C.Targeted Drug 

Treatment of pancreatic cancer depends on several factors such as the stage of the disease, location of the tumor, the age and condition of the patient. It is a multidisciplinary approach to define the best treatment options

Treatment options include surgery, chemotherapy, and radiation.

A. Surgery

Surgery is generally considered as a cure if the tumor is confined to the pancreas. In inoperable cases, it is done only as a palliative option to keep the patient comfortable and free from pain.

Tumor of Head of Pancreas

For tumors involving the head, Whipple’s procedure is performed. The gallbladder and a part of the bile duct may also be removed. The remaining parts of the pancreas and small intestine are reconstructed to allow passage of food and digestion.

B.Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. They may be administered orally or intravenously and singly or in combination.

For patients who undergo surgery, adjuvant treatment with the chemotherapy drug gemcitabine lengthens survival. The targeted anti-cancer drug erlotinib (Tarceva®) has also demonstrated a small improvement in advanced pancreatic cancer survival when used in combination with gemcitabine. More recently, combination chemotherapy with FOLFIRINOX has shown an overall survival (OS) benefit of approximately 11 months versus about 6.5 months for gemcitabine alone, and gemcitabine plus abraxane has shown an OS of 8.5 versus 6.5 for gemcitabine. Thus, for cancers that are unresectable, treatments including chemotherapy and targeted therapy may be able to control the disease and help patients live longer and feel better. Unfortunately, these treatments have not been shown to achieve longer-term survival.

  • Chemotherapy may be combined with radiation (chemoradiation) to treat locally invasive inoperable tumors of the pancreas.
  • Chemoradiation may also be tried after surgery to reduce the risk of recurrence.
  • In patients with inoperable and advanced metastatic disease, chemotherapy may be used alone or in combination with targeted drug therapy.

C. Targeted Drug Therapy

This uses drugs that target specific defects within the tumor cells. Treatment is aimed at preventing their growth and division. For this purpose, the drug Erlotinib is used with chemotherapy in patients with advanced disease.

 

D. Radiation

Its role in pancreatic cancer remains controversial. It has been recommended as an option to shrink the tumor before surgery in resectable tumors. However, its role in non-resectable tumors remains unresolved. Some recommend it as adjuvant treatment following curative surgery but its role still remains controversial.

E.  Role of Clinical Trials

The only curative treatment for pancreatic cancer is complete surgical resection. Unfortunately, fewer than 20% of patients are candidates for surgery, because pancreatic cancer is usually detected after it has spread. Cancers that cannot be treated with surgery are called “unresectable.” For those patients with localized disease and small cancers with no lymph node metastases and no extension beyond the capsule of the pancreas, complete surgical resection can yield 5-year survival rates of 18% to 24%. Approximately 80% of patients who undergo surgery eventually relapse and die from the disease, suggesting a need for effective strategies to eradicate minimal residual disease following surgery to prevent relapse.

Clinical trials test out new unproven drugs, new forms of therapy such as gene therapy, or new approaches to existing treatment. They do not guarantee a cure and may have unexpected side effects also.

However cancer clinical trials are closely monitored to ensure safety. Patients are offered access to treatment that is otherwise unavailable.

The patient and the family may weigh their options and decide to accept or reject the offer of a clinical trial.

 

 

 

The information in this document does not replace a medical consultation. It is for personal guidance use only. We recommend that patients ask their doctors about what tests or types of treatments are needed for their type and stage of the disease.

Sources:

  • American Cancer Society
  • The National Cancer Institute
  • National Comprehensive Cancer Network
  • American Academy of Gastroenterology
  • National Institute of Health
  • MD Anderson Cancer Center
  • Memorial Sloan Kettering Cancer Center
  • American Academy of Hematology

 

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