Pancreatic cancer Overview

Understanding your pancreas

Your pancreas is about 6 inches (15 centimeters) long and looks something like a pear lying on its side. It releases (secretes) hormones, including insulin, to help your body process sugar in the foods you eat. And it produces digestive juices to help your body digest food and absorb nutrients.

Pancreatic cancer

Pancreatic cancer begins in the tissues of your pancreas — an organ in your abdomen that lies behind the lower part of your stomach. Your pancreas releases enzymes that aid digestion and produces hormones that help manage your blood sugar.

Several types of growths can occur in the pancreas, including cancerous and noncancerous tumours.

The most common type of cancer that forms in the pancreas begins in the cells that line the ducts that carry digestive enzymes out of the pancreas (pancreatic ductal adenocarcinoma). Cancers of lower bile duct and duodenum /proximal small intestine also behaves in more or less the same way as the pancreatic head cancer or the peri ampullary cancer.

Pancreatic cancer is seldom detected at its early stages when it's most curable. This is because it often doesn't cause symptoms until after it has spread to other organs.

Pancreatic cancer treatment options are chosen based on the extent of the cancer. Options may include surgery, chemotherapy, radiation therapy or a combination of these.

Symptoms

Signs and symptoms of pancreatic cancer often don't occur until the disease is advanced. They may include:

• Abdominal pain that radiates to your back

• Loss of appetite or unintended weight loss

• Yellowing of your skin and the whites of your eyes (jaundice)

• Light-colored stools

• Dark-colored urine

• Itchy skin

• New diagnosis of diabetes or existing diabetes that's becoming more difficult to control

• Blood clots

• Fatigue

When to see a doctor

See your doctor if you experience any unexplained symptoms that worry you. Many other conditions can cause these symptoms, so your doctor may check for these conditions as well as for pancreatic cancer.

Causes

It's not clear what causes pancreatic cancer. Doctors have identified some factors that may increase the risk of this type of cancer, including smoking and having certain inherited gene mutations.

How pancreatic cancer forms

Pancreatic cancer occurs when cells in your pancreas develop changes (mutations) in their DNA. A cell's DNA contains the instructions that tell a cell what to do. These mutations tell the cells to grow uncontrollably and to continue living after normal cells would die. These accumulating cells can form a tumor. When left untreated, the pancreatic cancer cells can spread to nearby organs and blood vessels and to distant parts of the body.

Most pancreatic cancer begins in the cells that line the ducts of the pancreas. This type of cancer is called pancreatic adenocarcinoma or pancreatic exocrine cancer.

Less frequently, cancer can form in the hormone-producing cells or the neuroendocrine cells of the pancreas. These types of cancer are called pancreatic neuroendocrine tumors, islet cell tumors or pancreatic endocrine cancer.

Risk factors

Factors that may increase your risk of pancreatic cancer include:

• Smoking

• Diabetes

• Chronic inflammation of the pancreas (pancreatitis)

• Family history of genetic syndromes that can increase cancer risk, including a BRCA2 gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma (FAMMM) syndrome

• Family history of pancreatic cancer

• Obesity

• Older age, as most people are diagnosed after age 65

Combination of smoking, long-standing diabetes and a poor diet increases the risk of pancreatic cancer beyond the risk of any one of these factors alone.

Complications

As pancreatic cancer progresses, it can cause complications such as:

• Weight loss. A number of factors may cause weight loss in people with pancreatic cancer. Weight loss might happen as the cancer consumes the body's energy. Nausea and vomiting caused by cancer treatments or a tumor pressing on your stomach may make it difficult to eat. Or your body may have difficulty processing nutrients from food because your pancreas isn't making enough digestive juices.

• Jaundice. Pancreatic cancer that blocks the liver's bile duct can cause jaundice. Signs include yellow skin and eyes, dark-colored urine, and pale-colored stools. Jaundice usually occurs without abdominal pain. Your doctor may recommend that a plastic or metal tube (stent) be placed inside the bile duct to hold it open. This is done with the help of a procedure called endoscopic retrograde cholangiopancreatography (ERCP). During ERCP an endoscope is passed down your throat, through your stomach and into the upper part of your small intestine. A dye is then injected into the pancreatic and bile ducts through a small hollow tube (catheter) that's passed through the endoscope. Finally, images are taken of the ducts.

• Pain. A growing tumor may press on nerves in your abdomen, causing pain that can become severe. Pain medications can help you feel more comfortable. Treatments, such as radiation and chemotherapy, might help slow tumor growth and provide some pain relief.

In severe cases, your doctor might recommend a procedure to inject alcohol into the nerves that control pain in your abdomen (celiac plexus block). This procedure stops the nerves from sending pain signals to your brain.

• Bowel obstruction. Pancreatic cancer that grows into or presses on the first part of the small intestine (duodenum) can block the flow of digested food from your stomach into your intestines.

Your doctor may recommend that a tube (stent) be placed in your small intestine to hold it open. In some situations, it might help to have surgery to place a temporary feeding tube or to attach your stomach to a lower point in your intestines that isn't blocked by cancer.

Prevention

You may reduce your risk of pancreatic cancer if you:

• Stop smoking. If you smoke, try to stop. Talk to your doctor about strategies to help you stop, including support groups, medications and nicotine replacement therapy. If you don't smoke, don't start.

• Maintain a healthy weight. If you are at a healthy weight, work to maintain it. If you need to lose weight, aim for a slow, steady weight loss — 1 to 2 pounds (0.5 to 1 kilogram) a week. Combine daily exercise with a diet rich in vegetables, fruit and whole grains with smaller portions to help you lose weight.

• Choose a healthy diet. A diet full of colourful fruits and vegetables and whole grains may help reduce your risk of cancer.

Consider meeting with a genetic counsellor if you have a family history of pancreatic cancer. He or she can review your family health history with you and determine whether you might benefit from a genetic test to understand your risk of pancreatic cancer or other cancers.

Diagnosis

Pancreatic ultrasound via endoscope

If your doctor suspects pancreatic cancer, he or she may have you undergo one or more of the following tests:

• Using a scope to create ultrasound pictures of your pancreas. An endoscopic ultrasound (EUS) uses an ultrasound device to make images of your pancreas from inside your abdomen. The device is passed through a thin, flexible tube (endoscope) down your esophagus and into your stomach in order to obtain the images.

• Removing a tissue sample for testing (biopsy). A biopsy is a procedure to remove a small sample of tissue for examination under a microscope. Most often the tissue is collected during EUS by passing special tools through the endoscope. Less often, a sample of tissue is collected from the pancreas by inserting a needle through your skin and into your pancreas (fine-needle aspiration).

• Blood test. Your doctor may test your blood for specific proteins (tumor markers) shed by pancreatic cancer cells. One tumor marker test used in pancreatic cancer is called CA19-9. It may be helpful in understanding how the cancer responds to treatment.

If your doctor confirms a diagnosis of pancreatic cancer, he or she tries to determine the extent (stage) of the cancer. Using information from staging tests, your doctor assigns your pancreatic cancer a stage, which helps determine what treatments are most likely to benefit you.

The stages of pancreatic cancer are indicated by Roman numerals ranging from 0 to IV. The lowest stages indicate that the cancer is confined to the pancreas. By stage IV, the cancer has spread to other parts of the body.

The cancer staging system continues to evolve and is becoming more complex as doctors improve cancer diagnosis and treatment.

Treatment

Treatment for pancreatic cancer depends on the stage and location of the cancer as well as on your overall health and personal preferences. For most people, the first goal of pancreatic cancer treatment is to eliminate the cancer, when possible. When that isn't an option, the focus may be on improving your quality of life and limiting the cancer from growing or causing more harm.

Treatment may include surgery, radiation, chemotherapy or a combination of these. When pancreatic cancer is advanced and these treatments aren't likely to offer a benefit, your doctor will focus on symptom relief (palliative care) to keep you as comfortable as possible for as long as possible.

Surgery – One of the most complex G I Surgery

Whipple’s procedure

Operations used in people with pancreatic cancer include:

Surgery for tumors in the pancreatic head. If your cancer is located in the head of the pancreas, you may consider an operation called a Whipple procedure (pancreaticoduodenectomy).

The Whipple procedure is a technically difficult operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, part of the bile duct and nearby lymph nodes. In some situations, part of the stomach and colon may be removed as well. Your surgeon reconnects the remaining parts of your pancreas, stomach and intestines to allow you to digest food.

• Surgery for tumors in the pancreatic body and tail. Surgery to remove the left side (body and tail) of the pancreas is called distal pancreatectomy. Your surgeon may also need to remove your spleen.

• Surgery to remove the entire pancreas. In some people, the entire pancreas may need to be removed. This is called total pancreatectomy. You can live relatively normally without a pancreas but do need lifelong insulin and enzyme replacement.

• Surgery for tumours affecting nearby blood vessels. Many people with advanced pancreatic cancer aren't considered eligible for the Whipple procedure or other pancreatic surgeries if their tumours involve nearby blood vessels. At highly specialized and experienced medical centers, surgeons may offer pancreatic surgery operations that include removing and reconstructing affected blood vessels.

Risk in surgery

Each of these surgeries carries the risk of bleeding and infection. After surgery some people experience nausea and vomiting if the stomach has difficulty emptying (delayed gastric emptying). Expect a long recovery after any of these procedures. You'll spend several days in the hospital and then recover for several weeks at home. This surgery does caries the risk of pancreatic leakage and henceforth further complications including massive bleeding and sepsis.

Extensive research shows pancreatic cancer surgery tends to cause fewer complications when done by highly experienced surgeons at centers that do many of these operations.

Chemotherapy

Chemotherapy uses drugs to help kill cancer cells. These drugs can be injected into a vein or taken orally. You may receive one chemotherapy drug or a combination of them.

Chemotherapy can also be combined with radiation therapy (chemoradiation). Chemoradiation is typically used to treat cancer that hasn't spread beyond the pancreas to other organs. At specialized medical centers, this combination may be used before surgery to help shrink the tumor. Sometimes it is used after surgery to reduce the risk that pancreatic cancer may recur.

In people with advanced pancreatic cancer and cancer that has spread to other parts of the body, chemotherapy may be used to control cancer growth, relieve symptoms and prolong survival.

Radiation therapy

Radiation therapy uses high-energy beams, such as those made from X-rays and protons, to destroy cancer cells. You may receive radiation treatments before or after cancer surgery, often in combination with chemotherapy. Or your doctor may recommend a combination of radiation and chemotherapy treatments when your cancer can't be treated surgically.

Radiation therapy usually comes from a machine that moves around you, directing radiation to specific points on your body (external beam radiation). In specialized medical centers, radiation therapy may be delivered during surgery (intraoperative radiation).

Traditional radiation therapy uses X-rays to treat cancer, but a newer form of radiation using protons is available at some medical centers. In certain situations, proton therapy can be used to treat pancreatic cancer and it may offer fewer side effects compared with standard radiation therapy.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care is not the same as hospice care or end-of-life care. Palliative care is provided by teams of doctors, nurses, social workers and other specially trained professionals. These teams aim to improve the quality of life for people with cancer and their families.

Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing medical care. It's often used while undergoing aggressive treatments, such as surgery, chemotherapy and radiation therapy.

When palliative care is used along with other appropriate treatments — even soon after the diagnosis — people with cancer may feel better and live longer.

Pancreatic cysts

Overview

Pancreatic cysts are saclike pockets of fluid on or in your pancreas. The pancreas is a large organ behind the stomach that produces hormones and enzymes that help digest food. Pancreatic cysts are typically found during imaging testing for another problem.

The main categories of pancreatic cysts can be divided into two groups, cancerous and non cancerous. Each group includes many different subtypes of cysts, such as pseudocysts, serous cystadenomas and mucinous cystic neoplasms. Most aren't cancerous, and many don't cause symptoms. But some pancreatic cysts can be or can become cancerous.

Your doctor might take a sample of the pancreatic cyst fluid to determine if cancer cells are present or suspected. Or your doctor might recommend monitoring a cyst over time for changes that indicate cancer.

Symptoms:

You may not have symptoms from pancreatic cysts, which are often found when imaging tests of the abdomen are done for another reason.

When signs or symptoms of pancreatic cysts do occur, they typically include:

• Persistent abdominal pain, which may radiate to your back

• Nausea and vomiting

• Weight loss

• Feeling full soon after you start eating

When to see a doctor

Rarely, cysts can become infected. See a doctor if you have a fever and persistent abdominal pain.

A ruptured pancreatic cyst can be a medical emergency, but fortunately it is rare. A ruptured cyst can also cause infection of the abdominal cavity (peritonitis).

Causes

The cause of most pancreatic cysts is unknown. Some cysts are associated with rare illnesses, including polycystic kidney disease or von Hippel-Lindau disease, a genetic disorder that can affect the pancreas and other organs.

Pseudocysts often follow a bout of a painful condition in which digestive enzymes become prematurely active and irritate the pancreas (pancreatitis). Pseudocysts can also result from injury to the abdomen, such as from a car accident.

Risk factors

Heavy alcohol use and gallstones are risk factors for pancreatitis, and pancreatitis is a risk factor for pseudocysts. Abdominal injury is also a risk factor for pseudocysts.

Prevention

The best way to avoid pseudocysts is to avoid pancreatitis, which is usually caused by gallstones or heavy alcohol use. If gallstones are triggering pancreatitis, you may need to have your gallbladder removed. If your pancreatitis is due to alcohol use, not drinking can reduce your risk.

Diagnosis

Types of pancreatic cysts

Pancreatic cysts are diagnosed more often than in the past because improved imaging technology finds them more readily. Many pancreatic cysts are found during abdominal scans for other problems.

After taking a medical history and performing a physical exam, your doctor may recommend imaging tests to help with diagnosis and treatment planning. Tests include:

•Computerized tomography (CT) scan. This imaging test can provide detailed information about the size and structure of a pancreatic cyst.

•MRI scan. This imaging test can highlight subtle details of a pancreatic cyst, including whether it has any components that suggest a higher risk of cancer.

•Endoscopic ultrasound. This test, like an MRI, can provide a detailed image of the cyst. Also, fluid can be collected from the cyst for analysis in a laboratory for possible signs of cancer.

•Magnetic resonance cholangiopancreatography (MRCP). MRCP is considered the imaging test of choice for monitoring a pancreatic cyst. This type of imaging is especially helpful for evaluating cysts in the pancreatic duct.

The characteristics and location of the pancreatic cyst, along with your age and sex, can sometimes help doctors determine the type of cyst you have:

•Pseudocysts are not cancerous (benign) and are usually caused by pancreatitis. Pancreatic pseudocysts can also be caused by trauma.

•Serous cystadenomas can become large enough to displace nearby organs, causing abdominal pain and a feeling of fullness. Serous cystadenomas occur most frequently in women older than 60 and only rarely become cancerous.

•Mucinous cystic neoplasms are usually situated in the body or tail of the pancreas and nearly always occurs in women, most often in middle-aged women. Mucinous cystadenoma is precancerous, which means it might become cancer if left untreated. Larger cysts might already be cancerous when found.

• An intraductal papillary mucinous neoplasm (IPMN) is a growth in the main pancreatic duct or one of its side branches. IPMN may be precancerous or cancerous. It can occur in both men and women older than 50. Depending on its location and other factors, IPMN may require surgical removal.

•Solid pseudopapillary neoplasms are usually situated in the body or tail of the pancreas and occur most often in women younger than 35. They are rare and sometimes cancerous.

•A cystic neuroendocrine tumor is mostly solid but can have cystlike components. They can be confused with other pancreatic cysts and may be precancerous or cancerous.

Treatment

Watchful waiting or treatment depends on the type of cyst you have, its size, its characteristics and whether it's causing symptoms.

Watchful waiting

A benign pseudocyst, even a large one, can be left alone as long as it isn't bothering you. Serous cystadenoma rarely becomes cancerous, so it also can be left alone unless it causes symptoms or grows. Some pancreatic cysts should be monitored.

Drainage

A pseudocyst that is causing bothersome symptoms or growing larger can be drained. A small flexible tube (endoscope) is passed through your mouth to your stomach and small intestine. The endoscope is equipped with an ultrasound probe (endoscopic ultrasound) and a needle to drain the cyst. Sometimes drainage through the skin is necessary.

Surgery

Some types of pancreatic cysts require surgical removal because of the risk of cancer. Surgery might be needed to remove an enlarged pseudocyst or a serous cystadenoma that's causing pain or other symptoms.

A pseudocyst may recur if you have ongoing pancreatitis.

MCN -Mucinous cyst adenoma will need surgery in order to prevent the possible conversion to cancer

SPT- Solid papillary tumour will also need surgery in order to prevent complications

IPMN – Needs surgery in most of the time in order to prevent future malignancy.

Chronic Pancreatitis

Pancreatitis is inflammation of the pancreas, the large gland located behind the stomach. People with chronic pancreatitis have persistent inflammation of the pancreas that leads to permanent damage.

The main function of the pancreas is to produce digestive enzymes and hormones, such as insulin, that regulate blood sugar levels. Damage to the pancreas can cause problems with digestion, absorption of nutrients, and production of insulin. As a result, people with chronic pancreatitis can lose weight, experience diarrhoea, become malnourished with vitamin deficiencies and develop diabetes.

It usually takes several years for permanent changes and symptoms to occur. Most cases of chronic pancreatitis are caused by long-standing over use of alcohol. Since only 5% to 10% of alcoholics develop chronic pancreatitis, there probably are other factors that influence whether someone develops chronic pancreatitis.

It is generally thought that people who continue to drink after one or more bouts of alcohol-related acute pancreatitis are more likely to develop chronic pancreatitis.

In some uncommon cases, a single severe episode of acute pancreatitis can cause enough damage that the disease becomes chronic.

Besides over us of alcohol, other causes of chronic pancreatitis include:

• Heredity -- Hereditary chronic pancreatitis is a rare genetic disorder that predisposes a person to develop the disease, usually before age 20.

• Genetic causes -- Mutations of the cystic fibrosis gene is the most widely recognized genetic cause.

• Blockage of the duct that drains digestive enzymes from the pancreas --If the enzymes don't drain properly, they can back up and damage the pancreas. Blockage can be caused by gallstones, scarring from prior surgery, tumors, or abnormalities of the pancreas or of the shape or location of the pancreatic duct. If the blockage is found early, surgery or a procedure called endoscopic retrograde cholangiopancreatography (ERCP) to relieve the blockage may help to prevent damage to the pancreas.

• Autoimmune pancreatitis -For unexplained reasons, some people develop antibodies that attack their own pancreas.

• Very high blood triglyceride levels

Sometimes the underlying cause of chronic pancreatitis cannot be identified.

Symptoms

The most common symptom is upper abdominal pain, which often radiates to the back and may be accompanied by nausea, vomiting and loss of appetite. The pain can occur daily or off and on, and can be mild or intense. As the disease gets worse and more of the pancreas is destroyed, pain may actually become less severe. During an attack, the pain often is made worse by drinking alcohol or eating a large meal high in fats.

Because a damaged pancreas can't produce important digestive enzymes, people with chronic pancreatitis may develop problems with digesting and absorbing food and nutrients. This can lead to weight loss, vitamin deficiencies, diarrhea and greasy, foul-smelling stools. Over time, a damaged pancreas also can fail to produce enough insulin, which results in diabetes.

Diagnosis

There is no single test that can be used to diagnose chronic pancreatitis. If you have long-lasting abdominal pain or signs that your food is not being properly absorbed, such as weight loss or greasy stools, your doctor will ask you about alcohol use, and other factors that increase your risk of chronic pancreatitis and other digestive problems.

The diagnosis of chronic pancreatitis can be made based upon:

• Typical symptoms

• Imaging studies that show damage and scarring of the pancreas

• The absence of another medical problem, such as cancer, to explain your symptoms and test results

Tests that may be done include:

• Blood tests to check for high levels of two pancreatic enzymes, amylase and lipase. These enzymes typically are elevated in people with acute pancreatitis, but are often normal in people with chronic pancreatitis.

• A computed tomography (CT) scan, magnetic resonance imaging (MRI), or ultrasound to detect inflammation, scarring, and possible tumors of the pancreas.

• A test called endoscopic retrograde cholangiopancreatography (ERCP), in which the patient swallows a small tube with a camera at the end, which passes through the stomach and into the small intestine. At the site where the bile and pancreatic ducts empty into the small intestine, dye is injected through a small tube into the ducts, which then light up on an X-ray. This technique allows your physician to look for blockages or damage to the ducts. In chronic pancreatitis, the pancreatic duct can appear a certain way during ERCP.

• A noninvasive imaging test called magnetic resonance cholangiopancreatography (MRCP), which evaluates the ducts without requiring an endoscope or contrast material.

Expected Duration

Once the cells of the pancreas have been destroyed, they do not regenerate easily. For this reason, diabetes and other problems that are associated with chronic pancreatitis require long-term treatment. It is unclear why pain develops with chronic pancreatitis, but once chronic pain develops, it tends to be long-lasting or even lifelong. Many patients require long-term medications for pain.

Prevention

Since most cases of chronic pancreatitis are associated with alcohol use, the best way to prevent the problem is to avoid or limit alcohol use. Anyone who has had an episode of alcohol-related acute pancreatitis should stop drinking entirely to lower the possibility of developing chronic pancreatitis. People who have been diagnosed with chronic pancreatitis can prevent further damage by eliminating alcohol use.

If blocked bile or pancreatic ducts can be opened by surgery or ERCP, it may prevent further damage to the pancreas. If caught early, scarring can be minimized. However, only a minority of people with chronic pancreatitis actually benefit from this procedure.

Treatment

Because chronic pancreatitis cannot be cured, treatment is directed toward relieving pain, improving food absorption, and treating diabetes.

For milder types of pain, medications such as acetaminophen (DOLO) or Tramadol (CONTRAMOL) may help. Many people need narcotic medications to control the pain. Pain management can be very challenging and require the help of a pain specialist.

In rare cases, surgery to open blocked ducts or remove part of the pancreas may be done to relieve pain. (LPJ, DP)

Problems absorbing food, and the resulting vitamin deficiencies, can be helped by taking supplemental digestive enzymes in pill or capsule form. Your doctor also may recommend that you follow a low-carbohydrate, high-protein diet that also restricts some types of fats. Once digestive problems are treated, people often gain back weight and diarrhoea improves.

Diabetes caused by chronic pancreatitis almost always requires treatment with insulin.

Prognosis

Although chronic pancreatitis is an incurable condition, the severity, frequency and type of symptoms can vary. Some people — especially those who quit drinking alcohol entirely — have very mild or occasional symptoms that are easily managed with medications. Other people — especially those who continue to drink alcohol — can have disabling, daily pain and may require frequent hospitalizations.

When should I call my doctor?

• You have severe pain in your abdomen and you are vomiting.

• You have a fever.

• You continue to lose weight without trying.

• Your skin or the whites of your eyes turn yellow.

• You have questions or concerns about your condition or care.