Pancreatic Cancer and Treatment
Pancreatic Cancer Overview
Pancreatic Cancer was common only in older age people, but the scenario has changed. It’s more commonly seen in younger generation people across the world. Unknowingly, people mostly die due to the late diagnosis at the time of its advanced stage. Cancer symptoms include abdominal pain, jaundice, weight loss, and diabetes. Simple blood tests and abdominal CT scans are performed to diagnose the cancer stage. Treatment options such as Medical, Endoscopic, and Surgical procedures are used depending on the stage of cancer.
The pancreas is a little spongy type organ which is a part of the digestive system lying under the arch of the stomach and profound inside the mid-region back of the stomach and in front of the spine. Pancreas structure can be divided into 3 parts; Head, Body, and Tail as described in the image below. The broader part of the pancreas is called Head, the middle portion is called Body, and the end portion is called Tail. It is surrounded by other organs like liver, gallbladder, spleen, and the first portion of the small intestine.
The pancreatic enzymes are delivered in cells which are called acinar cells. This piece of the pancreas is known as the “Exocrine” piece of the pancreas. The clusters of acinar cells are discovered assembled all through the pancreas; these cells discharge salts and pancreatic enzymes into little tributaries which gather and transport this pancreatic liquid. These rivulets, in the end, assemble and blend into the waterway known as the pancreatic duct. This duct keeps running from left to along the length of the pancreas, in the end normally getting together with the bile duct and discharging its joined stomach related substance into the initial segment of the small bowel called the duodenum.
Moreover, the pancreas has a hormonal function. For instance, within particular groupings of cells called the Islets of Langerhans, the pancreas produces hormones which secrets into the bloodstream. These hormones have various impacts and will be tended in an oversimplified manner. Insulin is produced by beta cells in which its main function is to bring down the level of glucose in the blood. Glucagon produced by alpha cells tends to build up the level of glucose. Different other hormones and peptides are created by the pancreas including called somatostatin, a hormone which inhibits the discharge of insulin.
What is Pancreatic Cancer?
Pancreatic Cancer is a malignant tumor development in which a group of individual cells starts to develop in a faster state, in an uncontrolled and strange manner, which may spread by forceful nearby augmentation or by the seeding of different organs through vein channels or by means of the lymphatic framework.
There are also benign tumors or so-called pancreatic neuroendocrine tumors, which are not constantly less serious but have a tendency to develop slowly and efficiently, and which do not spread by colonizing into different parts of the body and this phenomenon is known as metastasis. This tumor can emerge from any sort of cell in the body.
In up to 90% of cases, pancreatic growth emerges from the exocrine portion of the organ. The minimum normal exocrine pancreatic growth originates from acinar cells. The greater part of the exocrine tumors is from ductal cells, which lines the pancreatic ducts. These tumors are specifically designed carcinomas emerging from a lining cell. Further, under the magnifying instrument (microscope), the appearance and course of action of these carcinoma cells can show up as duct-like or ‘adeno’ giving the name adenocarcinoma to this most common type of pancreatic tumor.
Around 75% of exocrine pancreatic disease emerges in the head of the pancreas and also in the neck portion of the pancreas, the parts through which the pancreatic duct runs just before it meets the duodenum. A portion of these carcinomas emerge in the body of the pancreatic organ, and 10% emerges in the tail of the pancreas, in the left territory, nearest to the spleen.
It is currently comprehended that the cancer is caused by the mutations of genes which represents increased development of potential to cells. Genes in which this potential is directly presented are called oncogenes. Different sorts of genes whose role incorporates that of preventing this phenomenon from happening are called tumor suppressor genes. Lastly, there is a third sort of gene called DNA-repair genes, the loss of capacity through change which may permit both activated oncogenes and ruined tumor-suppressor genes that leads to cancer. It is mostly believed that in excess of one mutation, modifying more than one pathway is vital for malignancy to happen.
An oncogene called K-ras is observed to be adjusted in up to 96% of ductal adenocarcinomas of the pancreas what we more often refer to as pancreatic cancer. Regular known tumor-suppressor genes which are inactivated by mutation in this sort of pancreatic cancer are p53 and p16 genes. For instance, p53 is inactivated in mostly 70% of adenocarcinomas of the pancreas. Still, other genetic mutations have been found. This zone of the request is presently a wellspring of research according to the cancer research, with an eye toward finding a powerful treatment or prior analysis of pancreatic cancer.
The symptoms can be identified by few early signs like the patient may experience:
- Generalized fatigue.
- Feeling very tired.
- Abdominal Pain or mid-back pain.
- Sudden weight loss.
- Jaundice (yellowishness in eye whites and skin).
- Light-colored stools.
- Dark yellow-colored urine.
- Loss of appetite.
- Nausea, vomiting, or diarrhea.
- Diabetes with no risk factors.
Conclusion of Symptoms:
One can say that the Pancreatic Cancer Symptoms are difficult to detect and diagnose in an early stage because of unnoticeable signs or symptoms in the early stages of cancer. Even when the symptoms are found it may relate to many other ailments or illnesses. Anyway, all the above signs and symptoms can be warranted through a medical evaluation and considering a second or third opinion from physicians.
Pancreatic cancer can be diagnosed with certain tests and procedures that give a clear picture of the health condition of the pancreas and its surrounding structures. Before that, by looking at the patient’s risk factors and past medical history of abdominal pain, jaundice, or weight loss it can be determined easily.
Using a process called staging, we can easily find out in what stage the cancer cells have spread on the pancreas and its surrounding areas. Only after the staging process is completed, the treatment plan can be decided whether the patient can benefit either from Medical therapy or Surgical therapy.
Through imaging studies such as abdominal MRI scans, PET scans, CT scans or CAT scans with or without dye, or even an ERCP (endoscopic retrograde cholangiopancreatography), a physician can easily diagnose pancreatic cancer. An abdominal ultrasound or an endoscopic ultrasound can be used to better correlate the other causes of abdominal pain or to rule out the main cause of it.
A tumor marker test procedure done by collecting samples of blood and urine or even a tissue sample to measure the carcinogenic substances such as CEA or CA19-9 produced by the organs containing tumor cells. When these substances are found in the increased level, it can give a clear picture of diagnosis.
With all the above diagnoses, pancreatic cancer can be staged into 4 categories from Stage 0 to Stage 4, where stage 4 will be the final stage where it would have spread to all other surrounding organs such liver, spleen or even lungs.
Stages of Pancreatic Cancer Explained:
According to the American Cancer Society, cancer stages can be classified into 4 groups Stage 0 to 4.
- Stage 0: Invisible on tests or imaging studies.
- Stage 1: Little to local growth less than 2 cm (stage 1A) within the pancreas and greater than 2 cm (stage 1B).
- Stage 2: Little to local spread greater than or equal to 4 cm growing outside the pancreas but limited to the surrounding structures or nearby lymph nodes.
- Stage 3: Widely spread to the nearby or major blood vessels or nerves, but attained the metastasis stage, difficult to live longer.
- Stage 4: Cancer has spread completely to the surrounding and the distant organs.
The cause and the risk factors involved in pancreatic cancer include:
- Obese or overweight.
- Age-related, maybe above 50 years of age.
- People of Ashkenazi Jewish heritage with BRCA2 gene mutations.
- History of Diabetes.
- History of Pancreatitis.
- Family history of Pancreatitis.
- Family history of Pancreatic Cancer.
- Family history of Pancreatic Cancer.
- Hereditary conditions like;
- Type 1 multiple endocrine neoplasia or MEN1 syndrome.
- Hereditary nonpolyposis colon cancer or HNPCC/Lynch syndrome.
- Hereditary breast and ovarian cancer syndrome.
- Von-Hippel-Lindau syndrome.
- Peutz-Jeghers syndrome.
- Familial atypical multiple mole melanoma or FAMMM syndrome.
There are different treatment options for Pancreatic Cancer depending on the disease stage and the location of the cancer cells spread through the surrounding organs. There are four to five standard treatment procedures known and performed in general namely;
- Surgical Therapy.
- Radiation Therapy.
- Targeted Therapy.
Surgical Therapy: Surgical resection performed to remove the pancreas is called as Surgical Therapy. Surgical therapy can be classified into 2 categories, potentially curative surgery and palliative surgery.
Potentially Curative Surgery (PCS): This surgery is done only when the Doctor feels that possible removal of all the pancreatic cancer tissues is possible, but the survival rates are pretty low in this case. It is a complex procedure where many complications are included. It can put the patient in a very hard condition where recovery period takes somewhere around from weeks to months. Three types of surgery can be performed under PCS;
- Whipple Procedure or pancreaticoduodenectomy.
- Distal Pancreatectomy.
- Total Pancreatectomy.
Palliative Surgery (PS): This surgery is done only when the Doctor feels that the cancer has spread to the nearby organs or structures to some extent to other part of the organs. In simple words, a complete resection or removal of the whole cancer spread areas is called Palliative Surgery.
Chemotherapy: A chemical or drug based therapy through where the drugs are taken through the mouth or intravenously (IV) which enters the bloodstream reaching the whole areas of the body to treat the cancer spread potentially. Chemotherapy drug is mostly used to treat pancreatic neuroendocrine tumors (NETs). This therapy is performed as an initial procedure before going to the surgery part and/or postsurgical procedure to treat the left over cancer cells.
Chemo drugs used in treating pancreatic cancer are;
- Oxaliplatin (Eloxatin).
- Paclitaxel (Taxol)
- Gemcitabine (Gemzar)
- Docetaxel (Taxotere)
- Irinotecan (Camptosar)
- Gemcitabine (Gemzar)
- Albumin-bound paclitaxel (Abraxane)
- Irinotecan liposome (Onivyde)
- 5-fluorouracil (5-FU)
Note: These drugs can cause possible side effects like loss of appetite, nausea or vomiting, mouth sores, hair loss, diarrhea or constipation, fatigue or shortness of breath, bruising or bleeding, etc.
Targeted Therapy: This therapy is a part of chemo-drug therapy or the next level of chemotherapy where certain drugs are developed to target the change in growth of pancreatic cancer cells. These drugs are developed to work when chemotherapy alone fails. These drugs have lesser side effects compared to the standard chemo-drugs. To mention one, erlotinib (Tarceva) is given in combination with gemcitabine in patients with advanced pancreatic cancer, which targets the cancer cells called epidermal growth factor receptors or EGFR, which helps the cell growth rate.
Radiation Therapy: Highly energized external beam radiations such like x-rays used to kill cancer cells is called Radiation Therapy. Radiation therapy is used both preoperatively and postoperatively depending upon the necessity and considering other factors
- Radiation therapy is used to help relieve pain symptoms in patients with advanced cancers or in people who are not considered as a candidate for surgery.
- Radiation therapy is given along with chemotherapy in locally advanced cancer stage or unresectable tumors.
- Radiation therapy is given along with chemotherapy preoperatively to shrink the size of the tumors making it easy for borderline tumor resection.
- Radiation therapy is given postoperatively as adjuvant therapy to reduce the recurring chance of the cancer growth. This therapy is mostly given in combination with chemotherapy, namely chemoradiation therapy.
Pancreatitis can be defined as inflammation of Pancreas where -itis defines inflammation of any given organ. Most probably pancreatitis can be classified into 3 groups. Firstly, Acute Pancreatitis, secondly Chronic pancreatitis, and thirdly autoimmune pancreatitis..
Acute Pancreatitis: A sudden or unexpected inflammation of the pancreas which occurs most commonly in patients leading to severe abdominal pain is called acute pancreatitis. It can be diagnosed with simple blood tests and abdominal CT scans. When acute pancreatitis is diagnosed, patients do require emergent medical attention even getting admitted to the Emergency Room is warranted. They may be placed n.p.o. (nothing by mouth) and place don IV fluids with pain medications for abdominal pain.
Chronic Pancreatitis: A prolonged or longstanding inflammatory disorder of the pancreas is called as pancreatitis. It may end up necessarily end up in gradual and progressive fibrosis of the gland and it results in most 3 common complications which include; chronic abdominal pain, endocrine, and exocrine insufficiency.
So, most commonly, the patients do seek medical attention when they experience chronic abdominal pain. Later stages of the disease are manifested mainly by exocrine insufficiency which leads to loose diarrhea and endocrine insufficiency or diabetes which is a common disease nowadays all over the world which needs to be managed typically in chronic pancreatitis patients.
Autoimmune Pancreatitis: This type of pancreatitis occurs very rare among people where it can result both in acute and chronic inflammation of the pancreas where the body itself attacks the pancreas in which it can lead to acute inflammation and slowly over time to chronic inflammation.
Difference between Acute pancreatitis and Chronic pancreatitis?
In simple words, acute pancreatitis is a short-term inflammation which can get better by proper medications and conservative measures whereas chronic pancreatitis is a long-term inflammation which can last long periods of time with recurring bouts of acute pancreatitis.
Treatment for Pancreatitis
There are three types of treatment to treat chronic pancreatitis, which include Medical, Endoscopic, and Surgical procedures.
Medical: In this treatment, it is mainly focused to treat the pain of chronic pancreatitis, which typically includes following a strict low-fat diet, avoiding alcohol consumption, avoiding all forms of tobacco products, introducing pancreatic enzyme supplements and pain medications. But, there is a lesser chance for most of the patients to respond to Medical Treatment.
Endoscopic: This treatment is a most commonly used method when patients fail to respond to Medical Treatment where they do end up having dilated pancreatic duct. Endoscopic Retrograde Cholangiopancreatography is the procedure which is performed to dilate the strictures and to remove any pancreatic duct stones and finally placing the pancreatic duct stents. Celiac Plexus Blockade with endoscopic ultrasound is another procedure used to alleviate the pain or relieve symptoms of pain associated with chronic pancreatitis as a short-term option.
Surgical: This is the last option to be considered when the above two fails to respond. Mostly for patients with small duct disease, Distal Pancreatectomy, Whipple Procedure or Total Pancreatectomy is performed. For patients with large duct disease, procedures such as Frey Procedure or Puestow procedure are performed. Total pancreatectomy can be performed with or without islet cell autotransplantation.
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