Pancreatic Cancer

What is pancreatic cancer?

Pancreatic cancer is the fourth most common cancer in men and women in the US, according to the American Cancer Society, which estimates that there will be 37,680  new cases and 34,290 deaths from pancreatic cancer in 2008. The majority of pancreatic cancer cases occur in people 50 years of age or older. Pancreatic cancer occurs when malignant cells grow out of control.

There are several types of exocrine pancreatic cancers, some of the more common ones are:

adenocarcinoma of the pancreas - the most common type of pancreatic cancer; occurs in the lining of the pancreatic duct.

intraductal papillary mucinous tumors (IPMN’s) – a cystic type of pancreatic tumor that can progress to cancer.

cystadenocarcinoma - a rare cystic pancreatic cancer.

There are several types of endocrine/islet cell tumors of the pancreas, including:

gastrinoma - a tumor which secretes above normal levels of gastrin, a hormone which stimulates the stomach to secrete acid and enzymes. Gastrinomas can cause peptic ulcers and diarrhea.

insulinoma - a rare pancreatic tumor that secretes insulin, the hormone that lowers glucose levels in the blood. This tumor is rarely malignant.

vipoma – a tumor that secretes vasoactive intestinal peptide, a hormone that causes a large volume of diarrhea.

glucagonoma - a tumor that secretes glucagon, a hormone which raises levels of glucose in the blood, leading to diabetes and a characteristic skin rash.

nonfunctional – a tumor that arises from the endocrine cells of the pancreas and may or may not secrete a hormone like pancreatic polypeptide (PPoma). These tumors do not cause hormonally related clinical symptoms. 

What are the risk factors for pancreatic cancer?

A risk factor is anything that may increase a person's chance of developing a disease. It may be an activity, such as smoking, diet, family history, or many other things. Different diseases, including cancers, have different risk factors.

Although these factors can increase a person's risk, they do not necessarily cause the disease. Some people with one or more risk factors never develop the disease, while others develop disease and have no known risk factors.

But knowing your risk factors to any disease can help to guide you into the appropriate actions, including changing behaviors and being clinically monitored for the disease.

Risk factors for pancreatic cancer, according to the National Cancer Institute, include:

• age - most pancreatic cancer occurs in people over the age of 60.
• smoking - cigarette smokers are two or three times more likely than non-smokers to develop pancreatic cancer.
• diabetes - pancreatic cancer occurs more often in people who have diabetes than in those who do not.
• gender - more men than women are diagnosed with pancreatic cancer.
• being African American  - African Americans are more likely than Asians, Hispanics, or Caucasians to be diagnosed with pancreatic cancer.
• family history - the risk for developing pancreatic cancer triples if a person's mother, father, or a sibling had the disease.
• chronic pancreatitis - this condition of the pancreas has been linked with increased risk for pancreatic cancer.

What are the symptoms of pancreatic cancer?

The following are the most common symptoms of pancreatic cancer. However, each individual may experience symptoms differently. Symptoms may include:

• pain in the upper abdomen or upper back
• loss of appetite
• weight loss
• jaundice (yellow skin and eyes, and dark urine)
• indigestion
• nausea
• vomiting

The symptoms of pancreatic cancer may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How are pancreatic tumors/cancers diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures for pancreatic tumors may include:

• ultrasound (also called sonography) - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of the abdomen such as the liver, spleen, and kidneys and to assess blood flow through various vessels.
• computed tomography (CT or CAT scan) - a diagnostic imaging procedure using a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
• magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
• endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope - a long, flexible, lighted tube. The scope is guided through the patient's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray.
• percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray.
• endoscopic ultrasound - an endoscopic ultrasound, or EUS, involves utilizing an endoscope (a thin, flexible tube) through a patient’s mouth to view the pancrease and biliary tract.  These days, this procedure is considered very accurate and the least invasive way to evaluate this area.  The procedure combines and endoscopy and ultrasound to obtain accurate images of the pancreatic and biliary tumors and also biopsy lesions using a small needle.  This procedure can also be used to deliver medications to reduce pain and discomfort in patients with advanced cancer.
• pancreas biopsy
• special blood tests
• positron emission tomography (PET) - a type of nuclear medicine procedure. This means that a tiny amount of a radioactive substance, called a radionuclide (radiopharmaceutical or radioactive tracer), is used during the procedure to assist in the examination of the tissue under study. Specifically, PET studies evaluate the metabolism of a particular organ or tissue, so that information about the physiology (functionality) and anatomy (structure) of the organ or tissue is evaluated, as well as its biochemical properties. Thus, PET may detect biochemical changes in an organ or tissue that can identify the onset of a disease process before anatomical changes related to the disease can be seen with other imaging processes such as computed tomography (CT) or magnetic resonance imaging (MRI).

Treatment for pancreatic cancer:

Specific treatment for pancreatic cancer will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the cancer or tumor
• type of cancer
• your tolerance of specific medicines, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Depending on the type and stage, pancreatic cancer may be treated with the following:

• surgery - surgery may be necessary to remove the tumor - a section or entire pancreas and/or the small intestine. The type of surgery depends on the stage of the cancer, the location and size of the tumor, and the person's health. Types of surgery for pancreatic cancer include the following:
  • Whipple procedure - if the tumor is located at the head of the pancreas (the widest part), the head of the pancreas, part of the small intestine, bile duct, and stomach, and other tissues will be removed.
  • distal pancreatectomy - if the tumor is located in the body and tail of the pancreas, both of these sections of the pancreas will be removed, along with the spleen.
  • total pancreatectomy - the entire pancreas, part of the small intestine and stomach, the common bile duct, the spleen, the gallbladder, and some lymph nodes will be removed.
• external radiation (external beam therapy) - a treatment that precisely sends high levels of radiation directly to the cancer cells. The machine is controlled by the radiation therapist. Since radiation is used to kill cancer cells and to shrink tumors, special shields may be used to protect the tissue surrounding the treatment area. Radiation treatments are painless and usually last a few minutes. Radiation therapy may be given alone, or in combination with surgery and chemotherapy.
• chemotherapy - the use of anticancer drugs to treat cancerous cells. In most cases, chemotherapy works by interfering with the cancer cell's ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells. The oncologist will recommend a treatment plan for each individual. Chemotherapy may be given alone, or in combination with surgery and radiation therapy.
• medication (to relieve or reduce pain)

Long-term prognosis for individuals with pancreatic cancer depends on the size and type of the tumor, lymph node involvement, and degree of metastases (spreading) at the time of diagnosis.

What is the Whipple procedure?

A surgical procedure used to remove the head of the pancreas. A Whipple procedure is usually performed for tumors of the head of the pancreas but it can also be done for pancreatitis or other benign conditions. Because the pancreatic head is surrounded by many important body structures like the duodenum, stomach, bile duct, and large arteries and veins, this procedure is very complex. Your surgeon can usually determine if your tumor can be removed surgically or not by obtaining a CT scan of the pancreas. A Whipple procedure can last anywhere from 4 to 8 hours. Most patients stay in the hospital 7-10 days and recover over a period of 2 months.

Can I have a minimally invasive pancreas operation?

Some tumors of the pancreas can be removed using minimally invasive techniques including laparoscopy or hand assisted laparoscopy. Each case will be evaluated individually to see if you are a candidate for these procedures.

Last updated 4/08 by Sohrab Mobarhan, MD.