Pancreatic Cancer

The pancreas is an elongated organ, which is located posteriorly, below the stomach within the curve of the upper part of small intestine, called the duodenum. It is composed of two types of glands; the exocrine and endocrine glands. The exocrine part plays an important role in digestion of fats, proteins and carbohydrates, by secreting digestive pancreatic juices and the endocrine part helps in keeping the blood sugar levels under control by secreting insulin.

Pancreatic cancer can originate in the exocrine or the endocrine glands, and this determines the type of the cancer

• Exocrine pancreatic cancer: These are of the most common type. These include:
  
  • Pancreatic ductal adenocarcinoma: accounts for 90% of the case of pancreatic cancer. It arises from the cells lining the ducts of the pancreatic glands.
  • Squamous cell carcinoma
  • Adenosquamous cell carcinoma
  • Colloid carcinoma
• Endocrine pancreatic cancer: These are also called the neuroendocrine or islet-cell tumours. These tumours can be ‘functional’ i.e. they secret extra amounts of hormones such as insulin, glucagon, gastrin, that cause different signs and symptoms or ‘non-functional’ i.e. they do not secrete extra hormones. These include:
  
  • Gastrinomas (secrete excess of gastrin hormone)
  • Glucagonomas (secrete excess of glucagon hormone)
  • Insulinomas (secret excess of insulin hormone)
  • Somatostatinomas (secrete excess of somatostatin hormone)
  • ‘VIP’ omas (Vasoactive intestinal peptide is secreted in excess)

Factors that increase the risk of pancreatic cancer include:

• Smoking
• Diabetes
• Chronic inflammation of the pancreas (pancreatitis)
• Family history of pancreatic cancer or genetic syndromes in families like BRCA2 gene mutation, Lynch syndrome and Familial atypical mole-malignant melanoma (FAMMM) syndrome are associated with increased risk of pancreatic cancer.
• Obesity
• Older age

The symptoms of pancreatic cancer may include:

• Abdominal pain that radiates to the back
• Loss of appetite or unintended weight loss
• Jaundice i.e. yellowish discoloration of skin and the ‘whites’ of the eyes
• Light or clay colored stools
• Dark colored urine
• Excessive skin itching
• Generalised weakness
• New diagnosis of diabetes or existing diabetes that's becoming more difficult to control

When to see the Doctor?

These symptoms can appear in any different form or characteristic, and hence it is best advised to consult our specialists to rule out any possibilities of cancer as a preventive measure if you are experiencing a combination of any of these symptoms.

• Physical examination: A through physical examination will be carried out after obtaining a detailed history of your symptoms.
• Physical examination: CT scan done with special technique called ‘Pancreatic protocol CT scan’ will be done, to determine the exact stage of the cancer, which in turn will help decide the best treatment sequence for a given patient.
• MRI scan: Sometimes, an MRI scan may be asked for as it gives better delineation of relation between vessels and tumour.
• PET CECT scan: A PET CT scan may sometimes be suggested to rule out spread of cancer to other sites like liver, lungs, etc.
• Biopsy/ FNAC: In patients with advanced diseases, in whom upfront surgery is not possible, but need treatment with chemotherapy or radiation, a small biopsy of an FNAC test will be done. There are different ways of performing this:
  
  • Endoscopic Ultrasound guided FNAC or biopsy: An endoscopic ultrasound or EUS is a device that uses ultrasound waves to create images of the pancreas inside the abdomen. The device is passed into your stomach from a thin and flexible tube called an endoscope and biopsy or FNAC can be obtained directly from the tumour.
  • USG guided Biopsy or FNAC: This is another method of obtaining biopsy or FNAC, wherein under USG guidance, a need le passed through the skin to obtain tissues or cells for confirming the type of pancreatic cancer.
  • Jaundice i.e. yellowish discoloration of skin and the ‘whites’ of the eyes

Treatments include:

• Surgery: Surgical procedures to remove cancer include:
  
  • Whipple’s procedure: In cancers involving the proximal part of pancreas, a Whipple’s procedure is usually performed. In this, the proximal part of pancreas along with adjacent small intestine (duodenum), distal part of stomach, gall bladder along with distal part of bile duct are removed along with adjacent lymph nodes. Reconstruction is then performed by joining a segment of small bowel (jejunum) with the remaining part of pancreas, bile duct and stomach.
  • Pylorus preserving pancreatico-duodenectomy: This surgery is similar to the Whipple’s procedure, except that distal part of stomach along with the pylorus (distal most part of stomach) is preserved.
  • Distal Pancreatico-splenectomy: For cancer involving the distal part of pancreas, a distal Pancreatectomy with or without splenectomy is performed.
  • Total Pancreatectomy: The removal of the pancreas in entirety is called Total Pancreatectomy. These patients need life long insulin and enzyme replacement.
  • Bypass surgeries: In some of advanced cases (stage IV), only bypass procedures are performed, like gastro-jejunostomy, hepatico-jejunostomy so that the patients jaundice comes down and he or she is able to eat well, during treatment
• Chemotherapy: Chemotherapy in the form of injections or tablets may be suggested depending on the stage of disease.
  
  • Adjuvant chemotherapy: Is the chemotherapy given after surgery, usually, 6 cycles every 2-3 weeks.
  • Neoadjuvant chemotherapy: When chemotherapy is given before surgery it is called neoadjuvant chemotherapy, wherein 3 cycles are given every 3 weeks, before surgery, the remaining 3 cycles then given as adjuvant chemotherapy, after surgery.
  • Chemo-radiation: Chemotherapy can also be recommended along with radiation treatment; called as concurrent chemo-radiotherapy, which can be used as neoadjuvant or adjuvant.
• Radiation therapy: Radiation therapy either alone or in combination with chemotherapy may be suggested depending upon the surgical histopathological report. Sometimes, concurrent chemo-radiation may be the only treatment decided, in patients with locally advanced disease wherein surgical resection cannot be performed safely.
• Targeted therapy: Targeted therapy uses drugs to target specific proteins within the cancer cells, to kill them. For example, Trastuzumab targeting Her2neu protein in pancreatic cancer cells expressing Her2neu protein may be suggested.
• Immunotherapy: In advanced cases, biological therapy or immunotherapy may be suggested for treatment. Immunotherapy targets the cells, which affect the body’s immune response and helps the body in killing cancer cells

Some of the preventive measures are:

• Stop smoking
• Maintain a healthy weight by exercising daily and eating healthy diet
• Consider meeting with a genetic counselor if you have a family history of pancreatic cancer.