Pancreas Cancer

1. What is pancreas? Where it is located?

The pancreas is a leaf shaped organ located in the back of the abdomen, behind the stomach, and in front of the vertebral column. It is a fleshy gland and is divided into head, body and tail. The bile duct, which is the last portion of outflow of bile from the liver, enters the pancreatic head before entering the duodenum (1st part of the small intestine). Thus, any tumor or swelling in the head results in obstruction to the flow of bile into the duodenum and this ultimately causes jaundice (also known as obstructive/surgical jaundice). The spleen is located close to the tail of the pancreas. While some cancers occur in the head of the pancreas, others occur in and around the terminal part of the common bile duct in close proximity to the duodenum and the pancreatic head (periampullary cancers). The two cancers though often used synonymously, vary in terms of survival and overall prognosis despite similar treatment options.

2. Why have I developed pancreatic/preiampullary cancer?

Development cannot be attributed to any single factor. There are multiple factors some of which are congenital and some acquired. The factors associated with development include cigarette smoking, diets rich in animal fact and meat, occupational exposure to certain chemicals like naphthylamine and benzidine, and sometimes, pre-existing chronic pancreatitis. Persons with familial syndromes like ataxia telengiectasia, hereditary pancreatitis, familial multiple mole syndrome, etc. have also been found to be at an increased risk. However, patients can develop these cancers without any of these factors being present.

3. What are the symptoms of pancreatic/preiampullary cancer?

The presentation depends on the location of the tumor. Tumors located in the region of the head of the pancreas or in the pancreatic head itself, tend to present early as they obstruct the bile duct. This manifests in the form of obstructive jaundice which includes yellowish discoloration of the eyes and skin, high colored urine, itching all over the body and pale, bulky stools. Also, the jaundice may disappear and reappear if the tumor is located in the head of the pancreas (preiampullary). Pain can sometimes be a late feature due to the involvement of surrounding structures that indicate advanced disease. The compression of the duodenum by a large tumor leads to vomiting. The tumors in the body and tail unfortunately tend to present later as they are followed to grow to a large size without any specific symptoms. A lump in the abdomen and pain are the main features. Weight loss, loss of appetite, and back pain are also seen.

4. What investigations will I be subjected to?

The best investigation available today is a Triphasic Computed Tomography (CT) scan. This allows the visualization of the tumor as well as evidence of the spread of the tumor to the other organs in the abdomen. In case the tumor cannot be well appreciated on CT scan owing to its small size but a tumor is yet suspected, an Endosonography (EUS) or Magnetic Resonance Cholangio-Pancreatography (MRCP) can prove to be valuable investigations. Often patients are referred for side viewing duodenoscopy that allows visualization of preiampullary tumors and even permit a biopsy. Serum CA 19.9 (a blood test) is a useful marker of cancer of the pancreas that helps not only in diagnosis but also in detecting recurrence and metastasis after curative surgery in some patients. If an operation is being planned, some more tests may be necessary to decide fitness of the patient for general anaesthesia.

5. The biopsy does not show cancer. Does this mean I do not have cancer?

No, Pancreas is located in an area in which obtaining a biopsy is difficult. Cancer might be associated with other conditions like pancreatitis which makes it difficult for the pathologist to clearly diagnose cancer. The decision of treatment is based on not just the biopsy but also the findings of CT scan and MRCP, so if the findings on CT scan or MRCP are suspicious, your surgeons may yet decide to proceed with surgery despite biopsy being negative. There is a small chance that the final histopathology may not show cancer. But in majority of the case one can predict the presence of malignancy with fair degree of certainty.

6. At what stage is the cancer?

Accurate staging of pancreatic cancer is based on histopathology and will be possible only after surgery. Based on clinical and radiological findings, pancreatic cancer can be broadly classified into
(1) Early cancer - In which there is no disease found outside the pancreas.
(2) Locally advanced - When the disease has come out of the pancreas and is invading or involving lymph nodes the surrounding structures.
(3) Metastatic - When the disease has spread far from the pancreas. Most commonly this spread occurs into the liver.
7. Now that I have been diagnosed to have pancreatic cancer how will I be treated?
The treatment will be based on the stage of the disease and in early cancer the optimal treatment will be surgery, in locally advanced tumors the treatment will usually be chemotherapy and/or radiotherapy. If the cancer responds well and shrinks, surgery may be offered after chemotherapy.
In metastatic/advanced tumors, the treatment is usually chemotherapy or treatment directed towards controlling the symptoms (symptomatic care).
8. Which kind of surgery is done for pancreatic cancer?

The type of surgery depends on the side, size and extent of the tumor. The most commonly done surgery is Whipple's Surgery. In this surgery, the head of the pancreas, the duodenum, the gall bladder, and bile duct are removed and the remaining structures are joined together by 3 anastomosis, viz. pancreatojejunostomy/pancretogastrostomy, hepaticodochojejunostomy and gastrojejunostomy. Other procedures depending on the location included:

Distal pancreatectomy for removal of tumors in the body and tail.
Segmental and total pancreatectomies. These are not commonly performed.
9. Are there any alternatives besides surgery?

Till date, surgery is the only proven curative option for pancreatic cancers. All other options are still considered experimental.

10. The surgeon who I consulted earlier advised me biliary stenting. Is this necessary?

Different surgeons have different policies regarding preoperative stenting. Stenting is generally done with the belief that it is unsafe to operate when the serum bilirubin level is considered to be high. So when the bilirubin is above a certain limit some surgeon's advice placing a plastic stent across the obstruction. This helps relieve the jaundice and gives the patient a sense of well being by relieving the itching and improving his appetite and digestion. The problem with stenting is that it causes inflammation in and around the area to be operated making surgery difficult. The surgery is then delayed as it is preferable to wait for at least 6 weeks after stenting. There are now large studies which have shown that major surgery can be done with bilirubin as high as 20 mg%. Preoperative plastic stenting is now advised only when bilirubin is very high (>20), patient is nutritionally depleted, has severe symptoms like itching and when there is superadded infection leading to fever (cholangitis). In all other situations, patients can be directly subjected to surgery without preoperative endoscopic biliary stenting.

11. How do I prepare myself for surgery?

The preparation is generally similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anaesthetist's advice regarding the continuation of medications if you are on any. A high protein diet is preferred to improve the nutrition.

12. How major is the surgery? What are the possible complications?

The procedure is deemed as one of the most major operations in the abdomen and was associated with very high complications and even death in the past. Today, it is universally accepted that this surgery should only be performed in high volume centers where the morbidity should be around 20-25% and a risk of death should be less than 5%. This means that if 100 people are operated, less than 5%. This means that if 100 people are operated, less than 5 of them have a chance of death. The complications of Whipple's surgery (which involves removal of a portion of the pancreas) include:

Early - 1)  Leak of anastomosis
2)  Bleeding from the anastomosis
3)  Prolonged vomiting (Delayed gastric emptying)

Late - 1) Pancreatic Exocrine Insufficiency PEI - This is characterized by sense of abdominal fullness, steatorrhea (i.e. foul-smelling, bulky stools), discomforting abdominal pain, and weight loss which can be managed by supplementation of pancreatic enzymes. These enzymes may need to be taken along with every meal on a lifelong basis.

2) Diabetes Mellitus Diabetes may have to be managed with oral hypoglycemic agents or with insulin.

13. How long do I have to stay in the hospital?
In an uncomplicated case, hospital stay after surgery is usually 9-12 days. This may be longer when there are any complications.

14. Will I need any further treatment after surgery?
The decision about adjuvant treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. If any of the lymph nodes are positive and your general condition is good enough then you may be referred to the medical oncologist for, consideration for chemotherapy.

15. What will be my survival after surgery? Are there any chances of the cancer coming back?

The survival differs significantly between periampullary cancers and cancer of the head of the pancreas. It will also depend on the stage of the disease. In patients with periampullary cancer who undergo complete resection about 30 in 100 will survive and will be disease free at the end of 5 years. The same figure falls to 5-10 in patients with cancer of head of the pancreas. As of the date there is no foolproof way of predicting which patients will have recurrence and which patient will not. With better surgical techniques and modern chemoradiotherapy, the survival is now slowly improving.

16. Are there any special precautions I need to take to prevent cancer from coming back?

No there no such proven precautions.

17. How frequently should I follow up after surgery?

After completion of treatment you will be advised to follow up once in 3-4 months in the first 2 years. Then the frequency will be reduced to once in 6 months for the next 2-3 years. Subsequent follow up be once a year. During each follow up you will be asked to do certain blood tests especially CA19.9. You may also be advised to get an ultrasound/CT scan of the abdomen done.