Conditions:

Pancreatic Cancer

What is the pancreas?

The pancreas is a 15-20 cm organ that lies transversely, deep, within the upper abdomen. It is made up of four parts, namely the head, neck, body and tail.

The pancreas is made up of two different types of cells which have two main functions known as

1. Exocrine pancreas - produce enzymes following meals. These enzymes flow into the bowel and are required to digest food.
2. Endocrine pancreas - produce hormones which regulate the level of fuel available to the body. Insulin and glucagon are the most important of these hormones produced by the endocrine part of the pancreas. They regulate our blood glucose levels crucial in normal body function.

Both these function are crucial to life. Dysfunction of the exocrine portion leads to the inability to digest and absorb food leading to malnutrition. Dysfunction of the endocrine pancreas leads to diabetes.

Where do pancreatic cancers arise from?

Pancreatic cancers can arise from both types of cells within the pancreas. They most commonly arise from the exocrine pancreas and are adenocarcinomas is type. These cancers account for over 90% of all pancreatic cancers.

What causes adenocarcinoma of the pancreas?

Pancreatic cancers occur in approximately 1 in every 1000 people. Very little is known about the cause of pancreatic cancer, but it is seen more commonly in

1. Males compared to females
2. Advancing age
3. Black or Jewish background
4. Smokers

What symptoms does adenocarcinoma of the pancreas cause?

Unfortunately, pancreatic cancer often causes no symptoms until it is advanced. The most common symptoms it causes are

1. Jaundice
2. Weight loss
3. Vomiting
4. Pain in the upper part of the abdomen

How is adenocarcinoma of the pancreas diagnosed?

In most cases, patient symptoms and physical examination can lead to the suspicion of pancreatic cancer, but the following tests lead to the diagnosis

1. Blood tests - CA 19-9 is a specific tumour marker for pancreatic cancer. Very high levels can be used to diagnose pancreatic cancer, but moderately elevated levels can be due to other disorders of the pancreas. Similarly, a normal CA 19-9 does not exclude the presence of cancer.
2. Ultrasound of the abdomen - similarly certain features on ultrasound can raise suspicion of cancer.
3. CT scan - this is the most common test that diagnoses pancreatic cancer. Again, a normal CT scan does not exclude cancer.
4. ERCP - this is a procedure similar to gastroscopy that allows a special type of X-ray of the pancreatic ducts to be performed that usually diagnoses pancreatic cancer. This is done in cases where pancreatic cancer is suspected, but a CT scan is normal.

How is pancreatic cancer treated?

The only way pancreatic cancer can be cured is by surgical removal of the tumour. Unfortunately, the majority of cancers are not diagnosed until the tumour is not curable. Therefore, the first step in treating a patient with newly diagnosed pancreatic cancer is to ascertain whether the tumour has spread away from the pancreas making it incurable. This process is known as staging. All of Dr Fenton-Lee's patients undergo the following staging procedures prior to surgery being contemplated

1. Blood tests - these can give clues to cancer spread to the liver.
2. Chest x-ray - looking for obvious spread to the lung.
3. CT san of the abdomen and chest - this is performed to ascertain spread to the lungs and liver.
4. Endoscopic Ultrasound - This procedure is similar to a gastroscope and is the best test to determine the depth and local invasion of the tumour. It also allows biopsies to be taken of surrounding lymph nodes to determine if they are involved which may alter the treatment plan.
5. Staging laparoscopy - This is the best test to look for small cancer nodules and lymph node involvement within the abdominal cavity that CT scan can miss. Laparoscopy is a minor procedure that is done when all other staging procedures are clear. It is done to prevent major surgery being performed in patients whose cancer is not curable.

Other tests that are sometimes used to look for cancer spread are PET scans and MRI scans.

Once all these staging procedures have been performed and are cleared, then surgery for pancreatic cancer can be considered. Click here to learn more about surgery for adenocarcinoma of the pancreas.

Can adenocarcinoma of the pancreas be cured?

Cure rates for adenocarcinoma of the pancreas are poor. This is because they are very aggressive and fast growing in nature and most patients have unresectable tumours at the time of diagnosis.

The prognosis of adenocarcinoma of the pancreas is calculated by staging that takes three factors into consideration. These factors are

1. Degree of tumour invasion (T staging)
2. Lymph node involvement (N staging)
3. Presence of distant metastases (M staging)

These factors are subcategorised into groups as follows

T staging
T1 - cancer limited to pancreas
T2 - tumour extending to duodenum, bile duct or peripancreatic
tissue
T3 - tumour extending directly to stomach, spleen, colon or major
vessels

N staging
N0 - No regional lymph node involvement
N1 - Regional lymph node involvement

M staging
M0 - No distant metastases
M1 - Distant metastases

The stage grouping and the 5 year survival for these groupings are as follows

What other types of pancreatic cancers are there?

Other, rarer tumours arising from the exocrine pancreas include

1. Cystadenoma.

Most cysts in the pancreas are not tumours, but approximately 10% are cystadenomas (cysts with abnormal cells). Of these, the majority are benign. A small percentage of these cysts however can be malignant.

It is often very difficult to distinguish between benign and malignant cysts clinically, by CT scans or even after they are removed and examined by pathologists. Due to this difficulty, suspected cystadenomas should be surgically removed if possible.

The overall prognosis for cystadenomas, even the aggressive malignant type, is much more favourable than adenocarcinoma of the pancreas.

2. Solid and Papillary Tumours

These types of tumours are rare and unusual and tend to occur in females in their third and fourth decades of life. They most commonly occur in the body or tail of the pancreas and can grow quite large. They have an excellent prognosis when surgically removed, but also have the potential to metastasise if left untreated.

3. Pancreatic lymphoma

Lymphoma is a type of cancer very similar to leukaemia that can occur in any lymph node of the body. It can also occur in the pancreas, but is rare.

As opposed to all other cancers in the pancreas, surgery has no role in the treatment of lymphoma. Instead, chemotherapy is used.

Can cancers arise from the endocrine part of the pancreas?

Yes, although these tumours are also rare, occurring in 5-10 per million. Collectively, they are termed "Islet Cell Tumours" after they cells from which they arise. They are a unique type of tumour whose behaviour varies greatly. They can behave in a benign or very aggressive manner. They are also unique in the sense that these tumours can overproduce hormones from the cells from which they arise. The most common examples of Islet Cell Tumours are

1. Insulinomas - the most common hormone producing Islet Cell tumour in the pancreas, they account for approximately 65% of Islet Cell Tumours. They arise from the b cells and as their suggests, produce insulin which leads to low glucose levels. Approximately 10% of these tumours are malignant. All suspected insulinomas should be surgically removed because of this risk.
2. Glucagonoma - account for approximately 15% of Islet Cell Tumours and are almost always malignant. They arise from the a cells of the pancreas and cause a syndrome of diabetes, weight loss, anaemia and a characteristic skin rash which is often diagnostic of glucagonomas. Due to there malignant nature, all glucagonomas should be surgically excised.
3. Somatostatinoma - very rare, produced from d cells in pancreas and cause diabetes, gallstones and fatty stools (steatorrhea). Almost all are malignant and should be surgically excised.
4. Gastrinoma - these tumours produce excessive amounts of a hormone known as gastrin which stimulates the stomach to produce acid, resulting in gastric ulcers. Approximately 70% of these tumours are malignant, but cure rates are excellent with surgical excision, even if they have metastasised. Gastrinomas are unusual in the sense that they can actually arise from sites other than the pancreas, the duodenum being the most common other source.
5. VIPomas - these are also exceedingly rare, but when they occur, cause large volumes of watery diarrhoea causing low potassium and chloride levels in the body. About half are malignant so as with all Islet Cell Tumours, should be surgically removed.

Despite the high malignant potential of Islet Cell Tumours, it is important to remember that they are rare and even in malignant cases, there prognosis is much better than adenocarcinoma of the pancreas.

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