Pancreatic cancer

Why pancreatic cancer develops

The most common type is ductal adenocarcinoma. The main risk factors are smoking, obesity, diabetes, chronic pancreatitis and age. About 5–10% of cases are hereditary: mutations in BRCA1, BRCA2, PALB2, Lynch syndrome, or pancreatic cancer in several relatives. That is why genetic testing is recommended for all patients: it affects both treatment choice and screening of the family.

Some cancers develop from cystic tumors — intraductal papillary mucinous neoplasms (IPMN). Cysts with risk features need surveillance or removal before cancer develops in them.

Are there symptoms

With a tumor in the head of the pancreas, the first sign is often painless jaundice: yellowing of the skin and eyes, dark urine, pale stools, itching. Tumors of the body and tail stay silent longer and show up as upper abdominal pain radiating to the back. Unexplained weight loss, loss of appetite, fatty stools and diabetes appearing for the first time after age 50 are also warning signs.

If jaundice appears, its cause must be established first, and bile drainage is done only when indicated — see the malignant obstructive jaundice page.

Examinations needed

• Pancreatic protocol CT — a multiphase contrast-enhanced scan showing the tumor and its relationship to the portal and superior mesenteric veins, the superior mesenteric artery, the celiac trunk and the hepatic artery. This determines whether surgery can be done straight away.
• Liver MRI — to look for small metastases that CT does not show.
• Endoscopic ultrasound with biopsy — confirms the diagnosis; a biopsy is mandatory if treatment starts with chemotherapy.
• CA 19-9 tumor marker — assessed once jaundice has been relieved; a very high level suggests likely occult spread.
• Diagnostic laparoscopy — when small peritoneal or liver metastases are suspected.
• Genetic testing for inherited mutations and molecular profiling of the tumor.

When surgery is possible

A tumor is considered resectable if it does not touch the major arteries, contact with the veins is minimal, and there are no distant metastases. These patients have surgery first, followed by adjuvant chemotherapy for about 6 months. With a high CA 19-9 or other signs of biologically aggressive disease, the MDT may recommend starting with chemotherapy.

If the tumor touches major vessels that can be removed and reconstructed, it is called borderline resectable; with deeper vascular involvement it is locally advanced. These patients receive chemotherapy first, after which surgery becomes possible for some — see the page on borderline resectable and locally advanced pancreatic cancer.

If surgery is not possible now

With distant metastases, treatment is based on combination chemotherapy; the regimen depends on general condition. Patients with an inherited BRCA mutation and no progression after at least 16 weeks of platinum chemotherapy may receive PARP inhibitor maintenance, and targeted drugs are available for rare molecular alterations.

Jaundice is treated with a bile duct stent, duodenal narrowing with a stent or a bypass, and pain — including with a celiac plexus block.

How the operation is performed

For a tumor in the head, a pancreaticoduodenectomy (Whipple procedure) is performed: the head of the pancreas, the duodenum, the gallbladder and the lower bile duct are removed with the lymph nodes, and then the remaining pancreas, the bile duct and the stomach are joined to a loop of small bowel. For tumors of the body and tail, a distal pancreatectomy is performed — removal of the body and tail with the spleen and lymph nodes. Sometimes the whole pancreas has to be removed.

If the tumor touches a vein, that segment of vein is removed with the tumor and reconstructed. Distal pancreatectomy is performed laparoscopically, through several small incisions, when the tumor’s location and the extent of resection allow.

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. The most common complications after a Whipple procedure are leakage from the pancreas-to-bowel connection (pancreatic fistula) and delayed gastric emptying; they are usually managed without reoperation, but the hospital stay is longer.

After surgery, enzyme supplements with meals are often needed, and some patients need treatment for diabetes. Adjuvant chemotherapy starts once the patient has recovered — ideally within the first 12 weeks.

Follow-up

For the first 2 years, CT and CA 19-9 every 3–6 months, then less often; the doctor sets the schedule. Weight, digestion, blood glucose and vitamin deficiencies are also monitored. Pain, jaundice or weight loss should be reported right away.

What to bring to the consultation

• pancreatic protocol CT and MRI discs with reports — the discs themselves, not just the reports;
• CA 19-9, bilirubin and chemistry panel results;
• the biopsy pathology or cytology report, if a biopsy was done;
• the procedure report and discharge summary, if a stent or drain has been placed;
• chemotherapy records and the genetic test result, if available.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.