How is pancreatic cancer diagnosed?
In order to diagnose pancreatic cancer, physicians will request a complete physical exam as well as personal and family medical histories. The way in which the cancer presents itself will differ depending on whether the tumor is in the head or the tail of the pancreas. Tail tumors present with pain and weight loss while head tumors present with steatorrhea, weight loss, and jaundice. Doctors also look for recent onset of atypical diabetes mellitus, Trousseau's sign, and recent pancreatitis.
In general, when making a pancreatic cancer diagnosis, physicians pay special attention to common symptoms such as abdominal or back pain, weight loss, poor appetite, tiredness, irritability, digestive problems, gallbladder enlargement, blood clots (deep venous thrombosis (DVT) or pulmonary embolism), fatty tissue abnormalities, diabetes, swelling of lymph nodes, diarrhea, steatorrhea, and jaundice.
It is also common for doctors to administer blood, urine, and stool tests. Blood tests can detect a chemical called carcinoembryonic antigen (CEA) as well as CA 19-9 - a chemical released into the blood by pancreatic cancer cells. Liver function tests check for bile duct blockage.
Several imaging techniques are employed in order to see if cancer exists and to find out how far it has spread. Common imaging tests include:
An ultrasound on the patient helps visualize a tumor
- Ultrasound - to visualize tumor
- Endoscopic ultrasound (EUS) - thin tube with a camera and light on one end
- Abdominal computerized tomography (CT) scans - to visualize tumor
- Endoscopic retrograde cholangiopancreatography (ERCP) - to x-ray the common bile duct
- Angiogram - to x-ray blood vessels
- Barium swallows to x-ray the upper gastrointestinal tract
- Magnetic resonance imaging (MRI) - to visualize tumor
- Positron emission tomography (PET) scans - useful to detect if disease has spread
The only absolute way to make a cancer diagnosis is to remove a small sample of the tumor and look at it under the microscope in a procedure called a biopsy. A fine needle aspiration (FNA) biopsy is the most commonly used method. A thin needle is inserted into the pancreas through the skin, and the pathologist uses CT scan or ultrasound images as a guide. Another type is the brush biopsy performed during ERCP to gather cells. A laparotomy is sometimes ordered to determine the stage, or extent, of the disease because it provides access to a large part of the abdominal cavity.
Stages of pancreatic cancer
After a diagnosis is made, doctors find out how far the cancer has spread to determine the stage of the cancer. The stage determines which choices will be available for treatment and informs prognoses. The standard pancreatic cancer staging method is called the TNM (Tumor - Node - Metastasis) system. T indicates the size and direct extent of the primary tumor, N indicates the degree to which the cancer has spread to nearby lymph nodes, and M indicates whether the cancer has metastasized to other organs in the body. A small tumor that has not spread to lymph nodes or distant organs may be staged as (T1, N0, M0), for example.
Group staging, from 0 to IV, for pancreatic cancer follows from TNM categories. Stage 0 is written as (Tis, N0, M0) where Tis stands for carcinoma in situ. This is when the tumor is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues nor spread outside of the pancreas. Stage IV is written as (Any T, Any N, M1) and describes cancer that has spread to distant sites throughout the body.
Physicians also use a simpler staging system that classifies tumors based on the likelihood that they can be surgically removed. Resectable cancers are isolated to the pancreas and can be entirely removed. Locally advanced (unresectable) tumors have not spread to distant organs but cannot be completely removed surgically. Metastatic tumors have spread to distant organs, and surgery would only be used to relieve pain or unblock ducts.
Treatments for pancreatic cancer
Cancer treatment depends on the type of cancer, the stage of the cancer (how much it has spread), age, health status, and additional personal characteristics. There is no single treatment for cancer, and pancreatic cancer is usually only curable when found in its earliest stages. Surgery, radiation, and chemotherapy are the most common treatment types. Treatments seek to remove the cancer and/or relieve painful symptoms that the cancer is causing.
Surgery may be used to remove all or part of the pancreas. If a cancer has not metastasized, it is possible to completely cure a patient by surgically removing the cancer from the body.
After the disease has spread, however, it is nearly impossible to remove all of the cancer cells.
There are three main surgical procedures that are used when it seems possible to remove all of the cancer:
- Whipple procedure (most common in cancers of the head of the pancreas): the pancreas head, and sometimes the entire organ, is removed along with a portion of the stomach, duodenum, lymph nodes, and other tissue. The procedure is complex and risky with complications such as leaking, infections, bleeding, and stomach problems.
- Distal pancreatectomy: the pancreas tail is removed, and sometimes part of the body, along with the spleen. This procedure is usually used to treat islet cell or neuroendocrine tumors.
- Total pancreatectomy: The entire pancreas and spleen are removed. Although you can live without a pancreas, diabetes often results because your body no longer produces insulin cells.
Palliative surgery is also an option when the cancer in the pancreas cannot be removed. Often, a surgeon will create a bypass around the common bile duct or the duodenum if either is blocked so that bile can still flow from the liver and pain or digestive problems can be kept at a minimum. Bile duct blockage can also be relieved by inserting a small stent in the duct to keep it open, a less invasive procedure using an endoscope.
Chemotherapy utilizes chemicals that interfere with the cell division process - damaging proteins or DNA - so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not necessarily just cancer cells), but normal cells can usually recover from any chemical-induced damage while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or metastasized because the medicines travel throughout the entire body. Treatment occurs in cycles so the body has time to heal between doses. However, there are still common side effects such as hair loss, nausea, fatigue, and vomiting. Combination therapies often include multiple types of chemotherapy or chemotherapy combined with other treatment options.
Gemcitabine (Gemzar) is the chemotherapy drug used most often to treat pancreatic cancer, and it is usually administered intravenously on a weekly basis. Another commonly used drug is 5-fluorouracil (5-FU). Chemotherapy is not always administered with the intent to cure the cancer. Some patients receive treatments after surgery (adjuvant therapy) to kill any cancer cells that were missed, and others receive it as palliative chemotherapy to improve their quality of life if the cancer cannot be cured.
Newer drugs that target specific parts of cancer cells are now being studied. These drugs work differently from standard chemotherapy drugs, and they often have fewer side effects. One such drug, erlotinib (Tarceva), has helped some patients with advanced pancreatic cancer and is taken orally in pill form. This drug has been used in combination with gemcitabine to show modest benefits.
Radiation treatment, also known as radiotherapy, destroys cancer by focusing high-energy rays on the cancer cells. This causes damage to the molecules that make up the cancer cells and leads them to commit suicide. Radiotherapy utilizes high-energy gamma-rays that are emitted from metals such as radium or high-energy x-rays that are created in a special machine. Radiotherapy can be used as a standalone treatment to shrink a tumor or destroy cancer cells, and it is also used in combination with other cancer treatments.
Radiation treatments for pancreatic cancer are usually given 5 days a week for 5 to 6 weeks. Patients may receive radiation treatment in addition to surgery, chemotherapy, or other treatments. In addition, radiation therapy can be palliative, serving to relieve pain or digestive problems when the common bile duct or duodenum is blocked.
Side effects of radiation therapy may include mild skin changes resembling sunburn or suntan, nausea, vomiting, diarrhea, and fatigue. Patients also tend to lose their appetites and have trouble maintaining weight, but most side effects subside a few weeks after completing treatment.
Using radioactive bacteria to stop the spread of pancreatic cancer - scientists from Albert Einstein College of Medicine of Yeshiva University used bacteria to carry radioisotopes commonly used in cancer treatment directly into pancreatic cancer cells. They found in animal experiments that the incidence of secondary tumors went down dramatically - i.e. the cancer was much less likely to spread (metastasize).
Claudia Gravekamp and team explained in the Proceedings of the National Academy of Sciences that they were immensely encouraged when they achieved a 90% reduction in metastases in the initial experiments.
Gravekamp said in a statement "At this point, we can say that we have a therapy that is very effective for reducing metastasis in mice."
This was achieved in mice with very aggressive pancreatic cancer, and with no harm to healthy tissue. Gravekamp added "With further improvements, our approach has the potential to start a new era in the treatment of metastatic pancreatic cancer."
Prevention of pancreatic cancer
There are no established guidelines or recommendations for preventing pancreatic cancer, according to the American Cancer Society. However, it is advisable to quit smoking because cigarette use is thought to be a main factor in 20-30% of pancreatic cancers. In general, physicians recommend standard preventive measures such as keeping a healthy weight, exercising, and increasing consumption of fruits, vegetables, and whole grains while decreasing red meat intake. There is no evidence, however, that following these dietary guidelines will prevent or reduce pancreatic cancer.
Some studies suggest that certain vitamins can reduce the risk of pancreatic cancer. Vitamin D has been associated with reducing the risk of several types of cancer, including pancreatic cancer. B vitamins such as B12, B6, and folate that are consumed in food (not in pill or tablet form) have also been suggested to reduce pancreatic cancer risk.
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