Cancer of Pancreas

Pancreatic cancer is relatively uncommon. It develops in about 1 in 10,000 people each year in the UK. There are several types of pancreatic cancer, but more than 9 in 10 cases are 'ductal adenocarcinomas'. Ductal adenocarcinoma of the pancreas This type of cancer develops from a cell which becomes cancerous in the pancreatic duct. This multiplies and a tumour then develops in and around the duct. As the tumour enlarges:

It can block the bile duct or the main pancreatic duct. This stops the drainage of bile and/or pancreatic fluid into the duodenum. It invades deeper into the pancreas. In time it may pass through the wall of the pancreas and invade nearby organs such as the duodenum, stomach or liver. Some cells may break off into the lymph channels or bloodstream. The cancer may then spread to nearby lymph nodes or spread to other areas of the body (metastasise).

Causes Overall, estimates indicate that 40% of pancreatic cancer cases are sporadic in nature. Another 30% are related to smoking, and 20% may be associated with dietary factors. Only 5-10% are hereditary in nature. Fewer than 5% of all pancreatic cancers are related to underlying chronic pancreatitis. Clinical Diagnosis The early clinical diagnosis of pancreatic cancer is fraught with difficulty. Unfortunately, the initial symptoms are often quite nonspecific and subtle in onset.

Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and mid-epigastric or back pain. Significant weight loss is a characteristic feature of pancreatic cancer. Pain is the most common presenting symptom in patients with pancreatic cancer. Typically, it is mid epigastric in location, with radiation of the pain sometimes occurring to the mid- or lower-back region. Radiation of the pain to the back is worrisome, as it indicates retroperitoneal invasion of the splanchnic nerve plexus by the tumor. Often, the pain is unrelenting in nature with night-time pain often being a predominant complaint. Some patients may note increased discomfort after eating. The pain may be worse when the patient is lying flat. Weight loss may be related to cancer-associated anorexia and/or subclinical malabsorption from pancreatic exocrine insufficiency caused by pancreatic duct obstruction by the cancer. Patients with malabsorption usually complain about diarrhea and malodorous, greasy stools. Nausea and early satiety from gastric outlet obstruction and delayed gastric emptying from the tumor may also contribute to weight loss. The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice.

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Patients with this sign may come to medical attention before their tumor grows large enough to cause abdominal pain. These patients usually notice a darkening of their urine and lightening of their stools before they or their families notice the change in skin pigmentation. Physicians can usually recognize clinical jaundice when the total bilirubin reaches 2.5-3 mg%. Patients and their families do not usually notice clinical jaundice until the total bilirubin reaches 6-8 mg%. Urine darkening, stool changes, and pruritus are often noticed by patients before clinical jaundice. Pruritus may accompany and often precedes clinical obstructive jaundice. Pruritus can often be the patient's most distressing symptom.

Physical signs Physical signs of pancreatic cancer may include weight loss, jaundice, abdominal mass, epigastric tenderness, palpable gallblader, and hepatomegaly; at least half of patients have no physical findings. Diagnostic Procedures Initial assessment There are many causes of jaundice and of the other symptoms listed above. Therefore, some initial tests are usually arranged if patients develop jaundice or the other symptoms listed above. Typically, these include an ultrasound scan of the abdomen and various blood tests. These initial tests can usually give a good idea if the cause of jaundice is a blockage from the head of the pancreas. Assessing the extent and spread

A CT scan (computerised tomography) is a commonly used test to assess pancreatic cancer. An MRI scan is sometimes done. An endoscopic ultrasound (EUS). A chest X-ray. A laparoscopy. This is using a laparoscope. A laparoscope is passed into the abdomen through a small incision (cut) in the skin.

Biopsy If a biopsy is thought to be needed then one way to get a sample from the pancreas is to take the biopsy sample when you have an endoscopy. This is done by passing a thin grabbing instrument down a side channel of the endoscope (gastroscope). Alternatively, sometimes a biopsy is done at the same time as having a scan. It can take two weeks for the result of a biopsy. Treatment Surgery

If the cancer is at an early stage, then there is a modest chance that surgery can be curative. (An early stage means a small tumour which is confined to within the pancreas and has not spread to the lymph nodes or other areas of the body).

If the tumour is in the head of the pancreas then an operation to remove the head of the pancreas may be an option. This is a long and involved operation as the surrounding structures such as the duodenum, stomach, bile duct, etc, need to be rearranged once the head of the pancreas is removed. If the tumour is in the body or tail of the pancreas then removal of the affected section of the pancreas is sometimes an option.

The reason why the chance of cure is only modest is because in a number of cases thought to be in an early stage, some cells have already spread to other parts of the body but are not yet detectable by scans or other staging tests. In time they grow into secondary tumours. If the cancer is at a later stage then surgery is not an option to cure the disease. Some surgical techniques may still have a place to ease symptoms. For example, it may be possible to ease jaundice caused by a blocked bile duct. A 'bypass' procedure may be used, or a stent may be inserted into the bile duct. (A stent is a small rigid tube made of plastic or metal which aims to keep a duct or channel open. It is usually inserted by instruments attached to an endoscope.) Chemotherapy Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells or stops them from multiplying. When chemotherapy is used in addition to surgery it is known as 'adjuvant chemotherapy'. Radiotherapy Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. Radiotherapy is not commonly used to treat pancreatic cancer. Overall survival is less than 5% at 5 years. Survival for distal lesions where radical pancreaticoduodenectomy is possible ranges from 16-68% at 5 years with an average of 42%. Midduct cancer for the most part is much less common and generally unresectable; 5-year survival is less than 5%. Carcinomas of the proximal ducts are resectable in only 30% to 40% of cases. There are some reported 5-year survivors; mean survival is 30 months.