Pancreatic Cancer – Risk Factors, Symptoms, Investigations, Staging, Treatment

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pancreatic-cancer

How a Patient with Pancreatic Cancer Presents?

To further understand the disease in a better way, have a look at the video below where CancerBro meets Mr. Parker who has recently being diagnosed with pancreatic cancer.

To understand the disease better, we will meet Mr. Parker pancreatic cancer patient, who has recently been diagnosed with cancer.

Mr. Parker is a 72 years old man, who was having abdominal pain for the last few days. Recently, he also noticed yellowish discoloration of his eyes. He got very worried and straight away rushed to the hospital.

After the complete diagnostic workup, he was found to have pancreatic cancer. Let’s meet him.

CancerBro: Hi Mr. Parker, how are you feeling today?

Mr. Parker: CancerBro, I was very worried when I was diagnosed with pancreatic cancer, but feeling a bit relaxed after talking to you.

CancerBro: What were your symptoms for which you consulted the doctor?

Mr. Parker: I had pain in the upper abdomen for the last few days, and also noticed yellowish discoloration of eyes and urine.

CancerBro: Mr. Parker, what work you do? After you physically active or mostly sedentary?

Mr. Parker: I work in a factory where I am continuously exposed to gases and my work is mostly sedentary. I am not much physically active.

CancerBro: What kind of diet do you take? Are you addicted to smoking or alcohol?

Mr. Parker: My diet is mostly unhealthy, with high carbohydrates and fats. I smoke almost a pack daily for the last 10 years.

CancerBro: Did anyone else in your close relative had a history of pancreatic or any other cancer?

Mr. Parker: No CancerBro, I don’t remember anyone with cancer in my family.

I think you people must have got an idea how a patient with pancreatic cancer presents, and what are the risk factors for the disease.

What are the Risk Factors for Pancreatic Cancer?

CancerBro, can you please discuss the risk factors in a little more detail.

Pancreatic cancer is more commonly seen in African Americans as compared to the natives.

Elderly males are more predisposed to the disease as compared to the females.

The disease is less commonly seen in white Americans and people from developed countries.

Smoking is a significant risk factor for pancreatic cancer, but the risk reduces significantly after cessation of smoking.

Exposure to chemicals or heavy metals, used in various industries may increase the risk of pancreatic cancer.

Obesity and physical inactivity is also a risk factor for the disease.

Regular physical activity may help in reducing the risk of pancreatic cancer.

High fat and high cholesterol diet may also be a risk factor for the disease.

History of pancreatic cancer in close relatives may also increase the risk in other family members.

Presence of diabetes or cirrhosis of the liver may also predispose a person to develop pancreatic cancer.

History of chronic or hereditary pancreatitis is also a risk factor for the disease.

These were the risk factors for pancreatic cancer.

Thanks, CancerBro. These risk factors if kept in mind may help us to contact the doctor early before the disease become very advanced.

Pancreatic Cancer Risk Factors

What are the Symptoms and Signs of Pancreatic Cancer?

CancerBro, what are the pancreas cancer symptoms?

The pancreatic cancer symptoms depend mainly on the site of the disease.

The most common site for pancreatic cancer is the head and uncinate process of the pancreas.

Jaundice and biliary colic are the most common symptoms produced by tumors in this location, due to the obstruction of the bile duct which passes through the head of the pancreas.

Due to the close proximity to the duodenum, head of pancreas tumors may lead to duodenal obstruction leading to GI distress.

Obstruction of the pancreas ducts may occur due to the tumors present in the head of the pancreas

Also by tumors present in other parts, such as the tail of the pancreas.

Obstruction of the pancreas duct may led to the development of acute pancreatitis, which presents as pain in the abdomen.

It also prevents the release of pancreas enzymes into the intestine, which presented as steatorrhea, or fatty stools.

Except these, other symptoms of pancreas cancer are, abdominal pain, aching/pressure/burring sensation in abdomen, loss of weight or appetite, and very rarely, venous thrombosis.

pancreatic cancer symptoms infographics

Symptoms of advanced disease may be caused due to local involvement of nearby structures and metastasis to distant sites.

Local spread may cause:

  • Upper abdominal or back pain/ discomfort
  • Nausea and/or vomiting
  • Loss of appetite, weight loss
  • Flatulence, dyspepsia and/or stool changes due to malabsorption
  • New onset diabetes
  • Yellowish discoloration of eyes and/ or urine

Distant spread may cause:

  • Jaundice, upper abdominal pain or discomfort
  • Chest pain or discomfort, cough, breathlessness
  • Ascitis or fluid collection in abdomen causing abdominal distension, bloating

Most common sites of spread of pancreatic cancer are liver, lung and peritoneum.

pancreatic cancer symptoms

What are the Investigations for Diagnosis and Staging of Pancreatic Cancer?

 

CancerBro, what are the investigations required to confirm the diagnosis of Pancreas cancer?

Investigations required to confirm the diagnosis of Pancreas cancer and stage the disease are imaging and endoscopic ultrasound.

Laparoscopic exploration of the abdomen may also be required in certain cases.

CT scan or ultrasound of abdomen is done when there is a suspicion of pancreatic cancer.

X-ray and CT scan of the chest may also be done if required.

Endoscopic ultrasound is an important investigation in the case of Pancreas cancer. It helps us to better localize and assess the spread of the tumor into the pancreas and adjacent structures. It also helps us to take a biopsy from the tumor for histopathological diagnosis. The biopsy may be is taken through the posterior wall of the stomach, when the cancer is located in the body or tail of the pancreas.

Laparoscopic exploration may be required in certain cases to better assess the spread of the tumor to peritoneum or other abdominal structures.

These were the pancreas cancer investigations required to confirm the diagnosis of cancer and stage the disease.

pancreatic cancer investigations for diagnosis and staging

What is the Normal Anatomy of Pancreas?

 

To understand the staging better, lets have a look at the normal anatomy of the pancreas.

This is the head of the pancreas, present in the right side of the abdomen, and is largest part of pancreas.

head of the pancreas

Neck is the narrow portion of pancreas that connects the head with body.

Neck is the narrow portion of pancreas

This prismatic shaped main structure of pancreas is called as body.

body of pancreas

This narrow down terminal portion of pancreas, present in the left side of the abdomen, is called as tail.

This narrow down terminal portion of pancreas, present in the left side of the abdomen, is called as tail

This look like projection from the lower part of head of pancreas is called as uncinate process.

uncinate process

This figure shows the location of pancreas in the abdomen.

location of pancreas in the abdomen

First part of the small intestine, called as duodenum curves along the head of pancreas.

duodenum

The spleen is located on the left side of abdomen, close to the tail of pancreas.

pancreatic tumor invades spleen

And here lies the left kidney, above which lies the suprarenal gland.

pancreatic tumor extends to left kidney and suprarenal gland

Superior mensentric artery is a branch of aorta, that crosses the uncinate process of the pancreas.

Superior mensentric artery

Bile duct passes through the head of the pancreas to join the duodenum.

bile duct

Main pancreatic duct passes from the tail to the head of the pancreas, and ultimately joins the duodenum.

Main pancreatic duct

This structure present above the pancreas is called as coeliac artery.

coeliac artery

It gives a branch on the right side, which is called as common hepatic artery.

common hepatic artery

And on the left is called as splenic artery.

pancreatic tumor extends to involve splenic artery

Behind the neck of the pancreas, the mesenteric vein and splenic vein join to form portal vein.

pancreatic tumor extends to involve portal vein

What is the TNM Staging of Pancreatic Cancer?

CancerBro, in my treatment summary, it was mentioned T2 N1 M0. What does that mean?

TNM is the staging system used for pancreatic cancer.

It is called as T1 when the tumor is less than 2 cm in size.

T1

T2 when the tumor is 2 to 4 cm in size.

T2

And T3, when the tumor is more than 4 cm in size.

T3

In T1 to T3 disease, the tumor may be limited to the pancreas and may be located in the head of the pancreas. Or tail, or any other part of the pancreas.

Or else, it may extend beyond the pancreas to involve the adjacent structures.

In this figure, cancer in the head of the pancreas invades the duodenum.

involves duodenum

Here, cancer in the pancreatic tail invades the spleen.

tumor invades the spleen

Here it extends to the left kidney and suprarenal gland.

extends to the left kidney and suprarenal gland

It may also extend also extend above, to involve splenic artery.

pancreatic tumor extends to involve splenic artery

Or behind, to invade the superior mesenteric vein.

Or splenic vein.

pancreatic tumor extends to splenic vein

Or portal vein.

pancreatic tumor extends to involve portal vein

Now we come to the T4 disease. In this figure, cancer has spread beyond the pancreas, to involve the common hepatic artery.

pancreatic tumor extends to involve portal vein

Infiltration into the coeliac artery is also T4 disease.

T4 - tumor involves coeliac artery

So is the involvement of the superior mesenteric artery.

T4 stage - pancreatic tumor involves superior mesenteric artery

pancreatic cancer T staging infographic (T3 and T4)

Now we come to the N staging or the nodal staging for pancreatic cancer.

It is called as node positive disease if cancer extends to involve the regional lymph nodes.

N stage

Regional lymph nodes may be different for the head, body, and the tail of the pancreas.

Lastly, we come to the M staging or the metastatic staging for pancreatic cancer. It is called as M1 when there is a spread of the tumor to distant organs.

In this figure, it has spread to the peritoneum, in form of multiple peritoneal deposits.

multiple peritoneal deposits

And here, it has spread to the liver in form of multiple nodular deposits.

pancreatic tumor spread to liver

This figure shows the spread of the tumor to the lungs.

pancreas tumor spread to lungs

Very rarely, it may also spread to brain or bones.

N and M staging infographic

T Staging

Tis – Pre-cancerous or cancer cells present only in the superficial layer of pancreatic duct cells

T1 – Cancer cells limited to pancreas and measures </=2 cm in largest dimension

T2 – Cancer cells limited to pancreas and measures >2 cm in largest dimension

T3 – Cancer cells have invaded the nearby organs such as duodenum, spleen, left kidney/adrenal gland, or splenic vein/superior mesenteric vein/portal vein

T4 – Cancer has invaded into the superior mesenteric artery or celiac artery

N Staging

N0 – No involvement of regional lymph nodes by cancer

N1 – Cancer has spread to nearby lymph nodes

M Staging

M0 – No spread of cancer to distant organs

M1 – Cancer that has spread to the distant organs such as lungs, bones, liver, peritoneum, and brain

What is the Treatment of Pancreatic Cancer?

Treatment of Localised and Locally Advanced Pancreatic Cancer

Now we will discuss the resectability of the pancreatic tumor, depending upon the extent of tumor.

Tumor located within the pancreas, without extension to adjacent structutes, is considered to be resectable.

This figure shows a resectable tumor located in the head of pancreas.

head of the pancreas tumor

Similarly, this is a resectable tumor located in the tail of pancreas.

tail of the pancreas tumor

A tumor located in the head of the pancreas, that extends to involve the duodenum, is also considered to be resectable.

involves duodenum

Similarly, tumors arising from the tail of pancreas, that involve the spleen, left kidney, or left suprarenal gland, may also be resected.

extends to spleen, left kidney, or left suprarenal gland

Superior mesenteric vein involvement maybe considered resectable, boderline resectable or unresectable, depending upon the extent of arterial involvement.

involves superior mesenteric vein

Similarly, involvement of portal vein maybe considered resectable, borderline resectable or unresectable, depending upon the extent of arterial involvement.

involves portal vein

Infiltration of tumor into common hepatic artery only, is borderline resectable in most of the cases.

pancreatic tumor extends to involve portal vein

Infiltration of tumor into the superior mesentric artery maybe considered borderline resectable or unresectable, depending upon the extent of arterial involvement.

T4 stage - pancreatic tumor involves superior mesenteric artery

Celiac artery involvement may also be borderline resectable or unresectable, depending upon the extent of arterial involvement.

infiltrates celiac artery

resectability depends on extent of tumor

Now we will discuss the treatment for all the three, that is resectable, borderline resectable, and unresectable disease.

Surgery is the treatment of choice of resectable disease, but chemotherapy may be added rarely for some high risk patients.

For borderline resectable patients, chemotherapy with or without radiotherapy is used, and then the decision for surgery is taken, depending upon the response to treatment.

And for unresectable patients, chemotherapy is the treatment of choice, and radiotherapy maybe used very rarely.

Non metastatic disease treatment infographic

The final decision is taken by the oncologist, on an individual patient basis, depending upon the performance status of the patient and exact stage of the disease.

Treatment of Metastatic Pancreatic Cancer

It may present as metastasis to peritoneum, in form of multiple peritoneal deposits.

metastasis to peritoneum

Or metastatis to liver,Lungs.

metastatis to liver                                             metastasis to lungs
Very rarely, it may also spread to brain or bones.

Chemotherapy is the treatment for choice for metastatic disease.

Also, radiotherapy, surgery, or bone directed therapy may be used for palliation.

Metastatic Disease treatment infographic

Treatment for metastatic disease is not generally curative.

Main intent of the treatment is prolongation of life, reduction of symptoms, and improvement in quality life.

With this, we come to the end of the treatment for pancreatic cancer.

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