Pancreatic cancer overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Pancreatic cancer is a malignant tumour within the pancreatic gland.
About 95 percent of pancreatic tumors are adenocarcinomas. The remaining 5 percent include other tumors of the exocrine pancreas (e.g. serous cystadenomas), acinar cell cancers, and pancreatic neuroendocrine tumors (such as insulinomas). These tumors have a completely different diagnostic and therapeutic profile, and generally a more favorable prognosis.[1]
Historical prospective
Pancreatic cancer was first discovered in the 18th-century by Italian scientist Giovanni Battista Morgagni.
Classification
Pancreatic cancer can be classified into malignant and borderline malignant. Duct cell carcinoma is the most common type of pancreatic cancer.
Pathophysiology
The pathophysiology of pancreatic adenocarcinoma includes considerable desmoplasia or formation of a dense fibrous stroma or structural tissue consisting of a range of cell types (including myofibroblasts, macrophages, lymphocytes and mast cells) and deposited material (such as type I collagen and hyaluronic acid).
Differentiating Pancreatic Cancer from other Diseases
Pancreatic cancer must be differentiated from choledocholithiasis, pancreatic pseudocyst, cystic neoplasm and carcinoma of the biliary tract
Epidemiology and Demographics
In the United States, the age-adjusted prevalence of invasive pancreatic cancer is 11.7 per 100,000 in 2011.[2] Pancreatic cancer is more prevalent in males than females.
Risk Factors
Pancreatic cancer is associated with number of predisposing risk factors such as age, gender, ethnicity, and environmental exposures.
Screening
In the general population, screening of large groups is not currently considered effective, although newer techniques, and the screening of tightly targeted groups, are being evaluated.[3][4] Nevertheless, regular screening with endoscopic ultrasound and MRI/CT imaging is recommended for pancreatic cancer in high risk individuals.
Natural History, Complications and Prognosis
Depending on the extent of the tumor at the time of diagnosis, the prognosis is generally regarded as poor, with complete remission extremely rare.[1]
Diagnosis
Staging
There are four stages of pancreatic cancer based on the size and extent of cancer spread.
History and Symptoms
Symptoms of pancreatic cancer include jaundice, light-colored stools or dark urine, pain in the upper/middle abdomen and back, weight loss, loss of appetite and fatigue.
Physical Examination
Physical examination of patients with pancreatic cancer is usually remarkable for tenderness, weight loss, and jaundice.
Laboratory Findings
Laboratory findings consistent with the diagnosis of pancreatic cancer include abnormal liver function tests and elevated CA 19-9 and CEA levels.
Chest X-ray
There are no chest X-ray findings associated with Pancreatic cancer
Ultrasound
On ultrasound metastasis to liver and fluid in the peritoneal cavity can be identified.
Other imaging findings
ERCP and PTC are other imaging techniques that can be used to diagnose pancreatic cancer.
Treatment
Medical Therapy
The therapy for pancreatic cancer depends largely on the disease progression and the stage of cancer. There are five different types of treatment for patients with pancreatic cancer: surgery, radiation therapy, chemotherapy, chemoradiation therapy and targeted therapy. In patients with pancreatic cancer, surgery is the primary modality of treatment. Extrapancreatic disease, in contrast, requires palliative therapy and curative resection is not performed in such patients. Patients with unresectable disease may be treated with chemotherapy and/or radiation therapy as a part of adjuvant or neoadjuvant therapy. Chemotherapy may be administered when surgical intervention is not deemed appropriate. The National Comprehensive Cancer Network (NCCN) has recommended guidelines for treatment in patients based on their performance status, which is a major prognostic factor. Performance status assesses extent of metastatic disease, size of the tumor and degree of weight loss. In patients with locally advanced unresectable or metastatic disease with good performance status, a combination of Leucovorin,5-fuorouracil, Oxaliplatin and Irinotecan (FOLFIRINOX) is preferred. Radiotherapy may form part of neoadjuvant therapy to attempt to shrink a tumor to a resectable state, but its use on unresectable tumors remains controversial. Neoadjuvant therapy may be used as the toxic effects of chemotherapy can be tolerated more easily before surgery as compared to after resection. Moreover, shrinkage of the tumor with neoadjuvant therapy makes resection easier and improves patient prognosis.
Surgery
The mainstay of therapy for pancreatic cancer is surgery. Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The method of surgical resection depends on the locally invasive characteristics and size of the neoplasm. The different surgical techniques that may be used for resectable pancreatic cancer include pancreaticoduodenectomy (Whipple Procedure), pylorus sparing Whipple procedure, distal pancreatectomy and total pancreatectomy. The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on resection margins, probability of cure, age and comorbidities. Curative resection is not contraindicated in all patients with vascular invasion, especially in cases with venous invasion. Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients. CA19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer. However, elevated levels of CA19-9 can help predict the likelihood of complete resection, the prognosis of patients with resectable disease and the presence of occult metastasis.
Primary Prevention
Primary prevention of pancreatic cancer involves the cessation of cigarette smoking, regular exercise and a healthy diet as per the American Cancer Society (ACS) guidelines. Cigarette smoking is considered to be the most significant modifiable risk factor for the development of pancreatic cancer. The risk of developing pancreatic cancer becomes almost equivalent to that of a nonsmoker after five years of smoking cessation. The American Cancer Society (ACS) has issued guidelines for diet and physical activity at both individual and community levels and advocates the intake of plenty of vegetables and fruits, protein from fowl and plant sources like whole grains and consumption of tuna, mackerel or salmon that are major sources of protein and long-chain omega-3 fatty acids.
Secondary Prevention
Secondary prevention of pancreatic cancer involves proper diet based on American Cancer Society (ACS) guidelines and palliative therapy for patients. Malabsorption may arise when pancreatic duct obstruction leads to exocrine pancreatic insufficiency. The diet proposed for pancreatic cancer patients is based on ACS guidelines and advocates administration of pancreatic enzyme replacement therapy, avoidance of high-protein/high-fat diets, individualized dietary prescriptions from a registered dietitian and dietary supplementation with omega-3 fatty acids. Palliative therapy is considered as an important part of secondary prevention and includes adequate analgesia, treatment of jaundice and duodenal obstruction, arising as complications of surgery.
References
- ↑ 1.0 1.1 Ghaneh P, Costello E, Neoptolemos JP (2007). "Biology and management of pancreatic cancer". Gut. 56 (8): 1134–52. doi:10.1136/gut.2006.103333. PMID 17625148.
- ↑ Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.
- ↑ He XY, Yuan YZ (August 2014). "Advances in pancreatic cancer research: moving towards early detection". World J. Gastroenterol. 20 (32): 11241–8. doi:10.3748/wjg.v20.i32.11241. PMC 4145762. PMID 25170208.
- ↑ Okano K, Suzuki Y (August 2014). "Strategies for early detection of resectable pancreatic cancer". World J. Gastroenterol. 20 (32): 11230–40. doi:10.3748/wjg.v20.i32.11230. PMC 4145761. PMID 25170207.