Pancreatic Cancer

"Cancers that develop within the pancreas fall into two major categories: (1) Cancers of the exocrine pancreas (the part that makes enzymes) and (2) Cancers of the endocrine pancreas (the part that makes insulin)."

Dharamshila Hospital And Research Centre is one of the top cancer hospitals of India for advanced cancer treatment

Dharamshila Hospital offers comprehensive care for patients with Pancreatic Cancer, including advanced diagnosis, best treatment options and rehabilitation services. Because successful pancreatic cancer treatment can be extremely complex, DHRC brings together a team of Surgical Oncologists, Gastroenterologists, Medical Oncologists, Radiation Oncologists, Pathologists, Radiologists, Pain Management Specialists and Nutritionists to assess each patient's needs.

Treatment teams at Dharamshila Hospital And Research Centre consider each patient's type and extent of Pancreatic Cancer to recommend the most appropriate treatment plan. They also carefully consider and select the treatment option that will make the patient disease free with good quality of life.

Cancers that develop within the pancreas fall into two major categories: (1) Cancers of the exocrine pancreas (the part that makes enzymes) and (2) Cancers of the endocrine pancreas (the part that makes insulin).

Exocrine Tumors

These are the most common type of pancreatic cancer tumors. The cells that secrete digestive enzymes form the exocrine part of the pancreas. Most of the exocrine pancreatic tumors are malignant in nature.

A majority of the exocrine pancreatic tumors are adenocarcinomas which account for about 95% of the cases. Adenocarcinomas are tumors that originate from glands and from glandular structures: the pancreatic adenocarcinomas usually originate from the ducts of the pancreas, but may also develop from the cells that make the pancreatic enzymes (acinar cell carcinomas).

Other forms of ductal cancers of the exocrine pancreas include adenosquamous carcinomas, squamous cell carcinomas, and giant cell carcinomas. These types are differentiated based on the microscopic characteristics of the cancerous cells.

The treatment of exocrine pancreatic cancer is mostly based on the stage of the cancer, not its exact type.

Another important type of cancer is the ampullary cancer (or carcinoma of the ampulla of Vater). Ampullary cancer develops where the bile duct and pancreatic duct come together and empty into the duodenum which is a part of the small intestine in continuity with the stomach. These tumors often block the bile duct while they are still small and have not spread far. This blockage causes the accumulation of bile, leading to yellowing of the skin and eyes (jaundice) and can turn the urine dark. Because of this, ampullary cancers are usually detected at an earlier stage than most pancreatic cancers, resulting in a relatively better outcome than typical pancreatic cancers.

Endocrine Tumors

The cells that secrete hormones constitute the endocrine portion of the pancreas. Tumors of the endocrine pancreas are less frequent. Collectively they are known as neuroendocrine tumors, or more specifically, islet cell tumors. There are several subtypes of islet cell tumors that are named according to the type of hormone secreting cells they originate from:

  • Insulinomas -arise from cells that make insulin
  • Glucagonomas -from cells that secrete glucagon
  • Gastrinomas -from cells that make gastrin (hormone released by stomach)
  • Somatostatinomas- from cells that make somatostatin
  • VIPomas come from cells that make vasoactive intestinal peptide (VIP)
These tumors are referred as "functioning" if they secrete hormones and "non-functioning" if they do not. Most functioning islet cell tumors are benign, while non-functioning tumors are more likely to be malignant. Treatment of these tumors depends on the specific type and stage (extent) of the tumor.
Because the pancreas lies deep in the belly in front of the spine, pancreatic cancer often grows silently for months before it is discovered. Early symptoms can be absent or quite subtle. More easily identifiable symptoms develop once the tumor grows large enough to press on other nearby structures such as nerves (which causes pain), the intestines (which affects appetite and causes nausea along with weight loss), or the bile ducts (which causes jaundice or a yellowing of the skin and can cause loss of appetite and itching). Symptoms in women rarely differ from those in men. Once the tumor sheds cancer cells into the blood and lymph systems and metastasizes, more symptoms usually arise depending on the location of the metastasis. Frequent sites of metastasis for pancreatic cancer include the liver, the lymph nodes, and the lining of the abdomen (called the peritoneum). Unfortunately, most pancreatic cancers are found after the cancer has grown beyond the pancreas or has metastasized to other places.

Other signs and symptoms may include:

  • Upper abdominal pain that may radiate to your back.
  • Yellowing of your skin and the whites of your eyes (jaundice).
  • Loss of appetite.
  • Weight loss.
  • Depression.
  • Blood clots.
If your doctor suspects pancreatic cancer, you may have one or more of the following tests to diagnose the cancer:

Imaging tests to create pictures of your internal organs - Imaging tests help your doctor visualize your internal organs, including your pancreas. Imaging tests used to diagnose pancreatic cancer include ultrasound, computerized tomography (CT) scan and magnetic resonance imaging (MRI).

An endoscopic ultrasound (EUS) uses an ultrasound device to make images of your pancreas from inside your abdomen. The ultrasound device is passed through a thin, flexible tube (endoscope) down your esophagus and into your stomach in order to obtain the images. Your doctor may also collect a sample of cells (biopsy) during EUS.

Endoscopic retrograde cholangiopancreatography (ERCP) uses a dye to highlight the bile ducts in your pancreas. During ERCP, an endoscope is passed down your throat, through your stomach and into the upper part of your small intestine. A dye is then injected into the pancreatic and bile ducts through a small hollow tube (catheter) that's passed through the endoscope. Finally, X-rays are taken of the ducts. A tissue or cell sample (biopsy) can be collected during ERCP.

Removing a tissue sample for testing (biopsy) - A biopsy is a procedure to remove a small sample of tissue from the pancreas for examination under a microscope. A biopsy sample can be obtained by inserting a needle through your skin and into your pancreas (fine-needle aspiration). Or it can be done using endoscopic ultrasound to guide special tools into your pancreas where a sample of cells can be obtained for testing.

Staging pancreatic cancer

Once a diagnosis of pancreatic cancer is confirmed, your doctor will work to determine the extent (stage) of the cancer. Your cancer's stage helps determine what treatments are available to you. In order to determine the stage of your pancreatic cancer, your doctor may recommend:

  • Laparoscopy uses a lighted tube with a video camera to explore your pancreas and surrounding tissue. The surgeon passes the laparoscope through an incision in your abdomen. The camera on the end of the scope transmits video to a screen in the operating room. This allows your doctor to look for signs cancer has spread within your abdomen.
  • Imaging tests. Imaging tests may include CT and MRI.
  • Blood test. Your doctor may test your blood for specific proteins (tumor markers) shed by pancreatic cancer cells. One tumor marker test used in pancreatic cancer is called CA19-9. Some research indicates that the more elevated your level of CA19-9 is the more advanced the cancer. But the test isn't always reliable, and it isn't clear how best to use the CA19-9 test results. Some doctors measure your levels before, during and after treatment. Others use it to gauge your prognosis.
Stages of pancreatic cancer

Using information from staging tests, your doctor assigns your pancreatic cancer a stage. The stages of pancreatic cancer are:

  • Stage I. Cancer is confined to the pancreas.
  • Stage II. Cancer has spread beyond the pancreas to nearby tissues and organs and may have spread to the lymph nodes.
  • Stage III. Cancer has spread beyond the pancreas to the major blood vessels around the pancreas and may have spread to the lymph nodes.
  • Stage IV. Cancer has spread to distant sites beyond the pancreas, such as the liver, lungs and the lining that surrounds your abdominal organs (peritoneum).

Tumour Board Evaluation

All patients who come to DHRC for oncology care start their treatment only after they have been discussed in the Tumor Board and given a Tumor Board Number. In the tumor board, all our specialists (Surgical Oncologists, Gastroenterologists, Medical Oncologists, Radiation Oncologists, Oncopathologist and Radiologists) discuss the findings, and chart out the optimal plan of treatment for each patient, based on established National and International Guidelines and Protocols. This treatment plan takes into account the overall health of the patient, the extent (stage) of the cancer and their preferences. The primary treatments for Osophageal Cancer include surgery, radiation therapy and chemotherapy.

Oncologists at DHRC see several thousand patients who have Osophageal Cancer each year. That experience helps them to guide patients toward the most appropriate treatment approach. We take great care to ensure patients understand the benefits and risks associated with each treatment option.

SURGERY

Surgery is the best option for people whose cancer can be safely and effectively removed. This usually means that the tumor hasn't grown into any of the major blood vessels located near the pancreas or spread to the liver, abdominal cavity or lungs.

Unfortunately, only about 20 percent of pancreatic cancer patients have tumors that can be surgically removed (resected). And although improvements in diagnosis, staging, surgical techniques and postoperative care have led to much better outcomes after surgery, pancreatic resection is still one of the most difficult and demanding operations for both surgeons and patients.

Pancreatic surgeries offered at DHRC

  • Whipple procedure - This is the most common type of surgery, also known as pancreatoduodenectomy (Whipple procedure) and is potentially curative. The surgery involves removing the "head" of the pancreas along with the duodenum, the gallbladder and the lower end of the bile duct. The bile duct, pancreatic duct and intestine are reconstructed. This is a technically demanding procedure, which our surgeons perform routinely, within acceptable rate of morbidty.
  • Other surgical procedures - DHRC offer other options for pancreatic cancer, including total pancreatectomy, which removes the entire pancreas, along with the gallbladder, part of the stomach and small intestine, the bile duct, spleen, and nearby lymph nodes; and distal pancreatectomy, in which the body and tail of the pancreas are removed.

RADIATION THERAPY AND MULTI-MODALITY THERAPIES

Radiation oncologists at DHRC have particular expertise in the most advanced therapies, including intensity modulated radiation therapy, which uses hundreds of small radiation beams of varying intensities to precisely target cancer cells, while sparing healthy tissue.

At DHRC, radiation is almost always given in conjunction with chemotherapy (chemoradiation) for tumors that can't be removed. It's also used before or after surgery to reduce the size of tumors and destroy cancer cells that may have spread beyond the pancreas.

Radiation can be delivered during surgery using intra-operative radiation electron therapy. Intra-operative radiation electron therapy allows doctors to treat tumors with high doses of radiation - the equivalent, in some cases, of 10 to 20 daily radiation treatments - without harming nearby organs.

CHEMOTHERAPY

Inoperable pancreatic cancers require the use of chemotherapy / radiation therapy to shrink / control the tumour growth. Pancreatic cancers with metastatic require chemotherapy. Selection of chemotherapeutic drugs, dosages and schedule depend on the physical condition of the patient and performance status. Patient not fit for injetable chemotherapy may also be offered targeted therapy.

PALLIATIVE CARE

When cancer is so advanced that treatment options are limited, an experienced, integrated team of palliative care providers serves the social, psychological and spiritual needs of patients and their families. The team may include physicians from a number of fields as well as dietitians, medical social workers, psychologists, pharmacists and pain management specialists.
Although there's no proven way to prevent pancreatic cancer, you can take steps to reduce your risk, including:

  • Stop smoking - If you smoke, stop. Talk to your doctor about strategies to help you stop, including support groups, medications and nicotine replacement therapy. If you don't smoke, don't start.
  • Maintain a healthy weight - If you currently have a healthy weight, work to maintain it. If you need to lose weight, aim for a slow, steady weight loss - 1 or 2 pounds (0.5 or 1 kilogram) a week. Combine daily exercise with a diet rich in vegetables, fruit and whole grains with smaller portions to help you lose weight.
  • Choose a healthy diet - A diet full of colorful fruits and vegetables and whole grains may help reduce your risk of cancer.
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