Pancreatic Cancer

What Is the Pancreas?

The pancreas is a 6-inch long, pear-shaped gland located deep in the abdomen between the stomach and the spine. The widest part of the pancreas is the head, the middle section is the body, and the thinnest part is the tail.

The pancreas makes insulin and glucagon that help control blood sugar levels. Both hormones help the body use and store the energy it gets from food. The hormones enter the bloodstream and travel through the body.

The pancreas also makes pancreatic juices that contain enzymes to help digest food. The pancreas releases the juices into a system of ducts leading to the common bile duct, which then empties into the duodenum, the first section of the small intestine.

The digestive juices are produced by exocrine pancreas cells and endocrine pancreas cells produce the hormones. About 95% of pancreatic cancers begin in exocrine cells.

What Is Pancreatic Cancer?

Cancer is abnormal cell growth that can occur in any part of the body. Normal, healthy cells grow, divide and replace themselves to maintain the natural order of living.

When cancer of the pancreas spreads (metastasizes) outside the pancreas, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, it means that cancer cells may have spread to other lymph nodes or other tissues, such as the liver or lungs.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if cancer of the pancreas spreads to the liver, the disease is metastatic pancreatic cancer, not liver cancer.

Symptoms

Pancreatic cancer is sometimes called a "silent disease" because early pancreatic cancer often does not cause symptoms. But, as the cancer grows, symptoms may include:

• Pain in the upper abdomen or upper back
• Yellow skin and eyes, and dark urine from jaundice
• Weakness
• Loss of appetite
• Nausea and vomiting
• Weight loss

These symptoms are not sure signs of pancreatic cancer. An infection or other problem could also cause these symptoms.

Diagnosing Pancreatic Cancer

To diagnose pancreatic cancer, your doctor may order one or more of the following procedures:

• CT scan. A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• Laparoscopy. A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions.
• Lab Tests. The doctor may take blood, urine, and stool samples to check for bilirubin and other substances. Bilirubin is a substance that passes from the liver to the gallbladder to the intestine. If the common bile duct is blocked by a tumor, the bilirubin cannot pass through normally. Blockage may cause the level of bilirubin in the blood, stool, or urine to become very high. Lab results also detect the absence of pancreatic enzymes as well as the presence of tumor markers including carcinoembryonic antigen, pancreatic oncofetal antigen, alfa-fetoprotein, and serum immunoreactive elastase I.
• ERCP (endoscopic retrograde cholangiopancreatography): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. An endoscope (a thin, lighted tube) is passed through the mouth, esophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. Tissue samples may also be taken.
• Ultrasonography. The ultrasound device uses sound waves that cannot be heard by humans. The sound waves produce a pattern of echoes as they bounce off internal organs. The echoes create a picture of the pancreas and other organs inside the abdomen. The echoes from tumors are different from echoes made by healthy tissues.The ultrasound procedure may use an external or internal device, or both types:
  • Transabdominal ultrasound: To make images of the pancreas, the doctor places the ultrasound device on the abdomen and slowly moves it around.
  • EUS (Endoscopic ultrasound): The doctor passes a thin, lighted tube (endoscope) through the patient's mouth and stomach, down into the first part of the small intestine. At the tip of the endoscope is an ultrasound device. The doctor slowly withdraws the endoscope from the intestine toward the stomach to make images of the pancreas and surrounding organs and tissues.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active than normal cells.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. There are several ways to do a biopsy for pancreatic cancer. A fine needle may be inserted into the pancreas during an x-ray or ultrasound to remove cells. Tissue may also be removed during a laparoscopy.
• Barium Swallow: The Barium Swallow test can locate and describe any irregularities in the normally smooth surface of the esophagus. Barium is a dense liquid used to coat the esophagus wall before an x-ray is taken. Barium is so dense that it does not allow x-rays to pass through it and shows up white on an x-ray. In addition to barium, air can be blown into the esophagus to help push the barium towards the esophagus wall and better coat the surface. When air is added to a barium swallow, it is called a double-contrast study.

Stages of Pancreatic Cancer

Once pancreatic cancer is diagnosed, your doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out the size of the tumor in the pancreas, whether the cancer has spread, and if so, to what parts of the body.

The following stages are used for adult pancreatic cancer:

In Stage I, cancer is found in the pancreas only. Stage I is divided into stage IA and stage IB, based on the size of the tumor. 

• Stage IA: The tumor is 2 centimeters or smaller.
• Stage IB: The tumor is larger than 2 centimeters. 

In Stage II, cancer may have spread to nearby tissue and organs, and may have spread to lymph nodes near the pancreas. Stage II is divided into stage IIA and stage IIB, based on where the cancer has spread.

• Stage IIA: Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.
• Stage IIB: Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.

In Stage III, cancer has spread to the major block vessels near the pancreas and may have spread to nearby lymph nodes.

In Stage IV, cancer may be of any size and has spread to distant organs, such as the liver, lung, and peritoneal cavity. It may have also spread to organs and tissues near the pancreas or to lymph nodes.

Recurrent pancreatic cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the pancreas or in other parts of the body.

Treatment Options

Treatment depends on where in the pancreas the tumor started, whether the disease has spread, and other factors such as your age and general health. Pancreatic cancer may be treated with surgery, radiation therapy, chemotherapy, or a combination of therapies.

Surgery may be used alone or in combination with radiation therapy and chemotherapy. The surgeon may remove all or part of the pancreas. The extent of surgery depends on the location and size of the tumor, the stage of the disease, and the patient's general health.

• Whipple procedure: If the tumor is in the head (the widest part) of the pancreas, the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach. The surgeon may also remove other nearby tissues.
• Distal pancreatectomy: The surgeon removes the body and tail of the pancreas if the tumor is in either of these parts. The surgeon also removes the spleen. 
• Total pancreatectomy: The surgeon removes the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
• Gastrojejunostomy:

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the abdomen. Radiation therapy may be given alone, or with surgery, chemotherapy, or both.

Radiation therapy is local therapy. It affects cancer cells only in the treated area. For radiation therapy, patients go to the hospital or clinic, often 5 days a week for several weeks.

Doctors may use radiation to destroy cancer cells that remain in the area after surgery. They also use radiation to relieve pain and other problems caused by the cancer.

Chemotherapy is the use of drugs to kill cancer cells. You doctor may also give chemotherapy to help reduce pain and other problems caused by pancreatic cancer. It may be given alone, with radiation, or with surgery and radiation.

Chemotherapy is systemic therapy. The doctor usually gives the drugs by injection. Once in the bloodstream, the drugs travel throughout the body.