Pancreatic Cancer: Causes, Symptoms, Treatment & Prognosis

Pancreatic cancer is known for its poor prognosis.Nearly more than 25,000 new pancreas cancer patients are diagnosed every year in India.It is 13th most common cancer but 5th most common cause of death due to cancer in India.Without treatment not more than 15% patient survive more than a year.With best treatment possible still less than 15% patient survive more than 5 years

Pancreatic Cancer Causes/Risk Factors

Smoking: It is most common risk factor.Nearly 75% patients are chronic smokers and risk equalize to non-smoker after 10 year of quitting it

Alcohol: It causes chronic inflammatory condition of the pancreas called chronic pancreatitis which is a risk factor for pancreatic cancer.

Recent studies show long term diabetes is also a risk factor. Pancreas cancer in itself can cause diabetes

Pancreatic Cancer Symptoms

Anorexia and Weight Loss: Are common especially when tumor is located at distal part of pancreas

Jaundice: Pancreas cancer located in the head obstruct the distal CBD and causes biliary obstruction which leads to jaundice. It is Surgical Obstructive Jaundice means patient present with features like pale colored stools, itching.

Vomitting: Tumor at pancreatic  head causes duodenal obstruction and patient present with features of Gastric outlet obstruction like vomiting.

Lump Abdomen: Tumor at distal pancreas can enlarge to big size before symptomatic and patient may present with lump abdomen

Diagnosis

USG Abdomen: When patient present with features suggestive of pancreas cancer then Ultrasound abdomen is the first investigation. Ultrasound can demonstrate mass in the pancreas, dilatation of the biliary tract, pancreatic duct dilatation, any associated lymph nodes and liver metastases if present.

CECT Whole Abdomen: If the tumor size is small then it may not be detected on USG then CECT abdomen is done. If the tumor is detected on ultrasound then also CT abdomen is done for tumor staging as CT gives more information than ultrasound

Treatment

The mainstay of pancreatic cancer treatment is surgical resection if the tumor is localized and the patient is fit for surgery. For locally advanced tumors before surgery chemotherapy is given by medical oncologist to make tumor resectable. Surgical procedure done is whipple procedure

What is Whipple procedure: WPD or Pancreatico-duodenectomy procedure is done for tumors located around periampullary region like head of pancreas, terminal part of CBD, and nearby duodenal areas. In this procedure gallbladder, distal CBD, Duodenum and head of pancreas are removed, then pancreas duct is anastomosed to jejunum (Pancreatico-jejunostomy), Bile duct is anastomosed to jejunum called as (Hepatico-jejunostomy) and then Gastro-jejunostomy is done

Pancreatic Cancer Treatment stage 4
Stage 4 Pancreatic cancer are metastatic. These patients require palliative therapy for symptoms like jaundice/Vomiting/Pain.There are two methods for palliation one is surgical other is endoscopically. If the patient is fit for surgery and tumor is not advanced surgical palliation is done. For vomiting due to gastric outlet obstruction caused by pancreatic had mass obstructing duodenum Gastro-jejunostomy is done. For jaundice biliary bypass is done most commonly hepatic-jejunostomy

Non-surgical palliative therapy include Endoscopically Biliary stenting for palliation of jaundice. Most commonly metallic stent is placed as it has got long life compared to plastic stent.Stent is placed in the duodenum for gastric outlet obstruction

The main stay of treatment for pain is oral analgesia. Celiac axis block is given under ultrasound guidance for severe pain abdomen not managed by either oral or intravenous analgesia

Management of Jaundice due to Pancreas Cancer

Cause of Jaundice: Mass located in the head of pancreas cause jaundice by direct compression over the CBD. Cancer in the body and tail region of pancreas can also cause jaundice by lymph nodal mass causing compression at the hepatoduodenal ligament
If the tumor is resectable high bilirubin level in these patients is not a contraindication for surgery. Pancreatic cancer jaundice treatment in these patients is definitive surgical procedure that is whipple procedure or Pancreatico-duodenectomy

Indications for Pre-operative biliary drainage in resectable cancer

Fever/bilirubin level more than 20/ pt not fit for surgery in view of malnutrition. Pre-operative ERC with biliary stenting is done. once the pt is fit for surgery definitive surgery is done

Palliative Surgery for Jaundice Treatment
If the tumor is found to be unresectable intra-operatively then palliative biliary bypass is done most commonly choledocho-jejunostomy is done. Cholecysto-jejunostomy is also an option in these patients.It is combined with gastro-jejunostomy as these patients have gastric outlet obstruction also

Palliative Endoscopic therapy for Jaundice Treatment
If the pancreatic cancer is unresectable or metastatic then ERC with biliary stenting is done by gastroenterologist to relieve from jaundice. Metallic stent is placed instead of plastic stent which has got long life

Prognosis

Pancreas cancer has got very bad prognosis; Its survival rate is poor one of the reason being it is diagnosed at late stage; if we compare stage by stage with other GI Cancer still its survival rate is poor

Prevention 

Prevention of risk factor such as smoking and alcohol are important steps for pancreas cancer prevention

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