Pancreatic Cancer

What is the pancreas?

The pancreas is a gland about 6 inches long that is shaped like a long, thin pear lying on its side. The wider end of the pancreas is called the head, the middle section is called the body, and the narrow end is called the tail. The pancreas lies behind the stomach and in front of the spine.

The pancreas has two main jobs in the body:
To produce juices that help digest (break down) food.
To produce hormones, such as insulin and glucagon, that help control blood sugar levels. Both of these hormones help the body use and store the energy it gets from food.

The digestive juices are produced by exocrine pancreas cells and the hormones are produced by endocrine pancreas cells. About 95% of pancreatic cancers begin in exocrine cells.

What causes pancreatic cancer?

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for pancreatic cancer include the following:

Smoking.
Long-standing diabetes.
Chronic pancreatitis.
Certain hereditary conditions, such as hereditary pancreatitis, multiple endocrine neoplasia type 1 syndrome (MEN-1 syndrome), hereditary nonpolyposis colon cancer (HNPCC; Lynch syndrome), von Hippel-Lindau syndrome, ataxia-telangiectasia, and the familial atypical multiple mole melanoma syndrome (FAMMM).

What are the symptoms of pancreatic cancer?

These and other symptoms may be caused by pancreatic cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

Jaundice (yellowing of the skin and whites of the eyes).
Pain in the upper or middle abdomen and back.
Unexplained weight loss.
Loss of appetite.
Fatigue.

Pancreatic cancer is difficult to detect and diagnose for the following reasons:

There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer.
The signs of pancreatic cancer, when present, are like the signs of many other illnesses.
The pancreas is hidden behind other organs such as the stomach, small intestine, liver, gallbladder,spleen, and bile ducts.

How is pancreatic cancer diagnosed and staged?

Pancreatic cancer is usually diagnosed with tests and procedures that produce pictures of the pancreas and the area around it. The process used to find out if cancer cells have spread within and around the pancreas is called staging. Tests and procedures to detect, diagnose, and stage pancreatic cancer are usually done at the same time. In order to plan treatment, it is important to know the stage of the disease and whether or not the pancreatic cancer can be removed by surgery. The following tests and procedures may be use:

Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly.
Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture called a sonogram. For pancreatic cancer diagnosis and staging the endoscope is inserted through the mouth while the patient sedated. The pancreas can be examined in great detail using EUS. Using a very thin needle passed down the endoscope and through the wall of the stomach or small intestine, EUS can also allow the doctor to take biopsies of the tumor or abnormal appearing lymph nodes.
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body.
PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
Surgery: Occasionally, pancreatic cancer is suspected, but can not be proven, despite extensive testing. Surgery, to examine and biopsy the pancreas directly may then be necessary.

How is pancreatic cancer treated?

Three types of standard treatment are used:

Surgery

One of the following types of surgery may be used to take out the tumor:

Whipple procedure: A surgical procedure in which the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
Total pancreatectomy: This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
Distal pancreatectomy: The body and the tail of the pancreas and usually the spleen are removed.

If the cancer has spread and cannot be removed, the following types of palliative surgery may be done to relieve symptoms:

Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area.
Gastric bypass: If the tumor is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. For pancreatic cancer, radiation therapy is typically used either to slow the growth and treat the pain of a tumor too advanced to remove by surgery or to shrink a tumor in hopes that future surgery will be possible.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Like radiation therapy, in pancreatic cancer, chemotherapy is primary used to slow the growth of a non-operable tumor or to shrink a tumor for potential future surgery.

Endoscopy

While endoscopic therapy does not cure or slow the growth of pancreatic cancer it can help relieve blockages caused by the growing tumor and improve quality of life.

Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is passed through the mouth, down to the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the bile duct or pancreatic duct. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken.
Enteral stenting: As a pancreatic cancer enlarges the tumor can invade or compress the small intestine blocking the flow of food and liquids. As this obstruction worsens, severe nausea and vomiting can occur, particularly after eating. During an upper endoscopy, a permanent expandable metal stent (tube) can be placed in the narrowed portion of the small intestine. Called an enteral stent, this procedure can relieve the blockage and allow the patient to continue eating regular foods.

What treatments are used for the pain caused by pancreatic cancer?

Pain can occur when the tumor presses on nerves or other organs near the pancreas. Oral pain medicine, typically narcotics, are the cornerstone of pain management in pancreatic cancer. Chemotherapy with or without radiation therapy can also help relieve pain by shrinking the tumor. When pain medicine is not enough, there are treatments that act on nerves in the abdomen to relieve the pain. Using endoscopic ultrasound to guide the needle, the doctor may inject medicine into the area around affected nerves to block the feeling of pain.

What is the chance of recovery?

The prognosis (chance of recovery) and treatment options depend on the following:

Whether or not the tumor can be removed by surgery.
The stage of the cancer (the size of the tumor and whether the cancer has spread outside the pancreas to nearby tissues or lymph nodes or to other places in the body).
The patient’s general health.
Whether the cancer has just been diagnosed or has recurred (come back).

Pancreatic cancer can be controlled only if it is found before it has spread, when it can be removed by surgery. If the cancer has spread, palliative treatment can improve the patient’s quality of life by controlling the symptoms and complications of this disease.