A National Cancer Institute-designated Comprehensive Cancer Center

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Pancreatic Cancer

About Pancreatic Cancer
Pancreatic cancer is a disease in which malignant (cancer) cells form in the tissues of the pancreas.

The pancreas is a gland about 6 inches long that is shaped like a thin pear lying on its side. The wider end of the pancreas is called the head, the middle section is called the body, and the narrow end is called the tail. The pancreas lies behind the stomach and in front of the spine.

The pancreas has two main jobs in the body:

 

  • To produce juices that help digest (break down) food.
  • To produce hormones, such as insulin and glucagon, that help control blood sugar levels. Both of these hormones help the body use and store the energy it gets from food.

The digestive juices are produced by exocrine pancreas cells and the hormones are produced by endocrine pancreas cells. About 95% of pancreatic cancers begin in exocrine cells.

The most common type of cancer of the pancreas is an adenocarcinoma of the pancreas (approximately 90 to 95%). Although it is the 4th leading cause of cancer deaths in men and women in the United States, survival is getting better everyday. Almost 30 to 40% of the patients have disease confined to the pancreas. It is important to find an experienced surgeon who can completely resect (remove) the cancer. There is growing evidence to suggest that post-op chemotherapy with or without radiotherapy improves long term survival and is slowly becoming the norm.
 
In over half of patients, the disease has sometimes grown beyond the pancreas. There two subtypes. One is locally advanced, i.e. involving the superior mesenteric vein or superior mesenteric artery. The second is the presence of metastatic disease, i.e. disease spread beyond the pancreas. Involvement of the portal vein or superior mesenteric vein does not always preclude surgery. So if your surgeon turns you down, a second opinion is in order. On the other hand, involvement of the superior mesenteric artery is a relative contraindication. However with slow growing tumors such neuroendocrine tumors, it may be reasonable to consider resecting this and reconstructing the artery with a graft.

Neuroendocrine tumor(s) of the pancreas
Cells that have both a neural component (receive messages via a nerve) and an endocrine component (respond by releasing a hormone) are called neuroendocrine cells. The pancreas and a few other organs have a relative abundance of neuroendocrine cells.
 
Less than 5% of pancreatic tumors are of neuroendocrine origin. There are two distinct types:

 

  • Pancreatic endocrine tumors (also know as endocrine tumors of the pancreas) or islet cell tumors of the pancreas.
  • Carcinoid tumors. These tumors have a completely different diagnostic and therapeutic profile, and generally have a more favorable prognosis.

There are several subtypes of islet cells.
  • The most common type is alpha cells producing glucagon (15% of total islet cells)
  • Beta cells producing insulin and amylin (75%), delta cells producing somatostatin (3 to 5%)
  • PP cells producing pancreatic polypeptide (3 to 5%), epsilon cells producing ghrelin (<1%)
  • Islet cell tumors can be functional (as in secrete excess hormones in to the body) or non-functional (do not secrete hormones).

 

Carcinoid tumors are cancerous, except they are slow growing.
This tumor is often associated with an increased production of serotonin (5-HT), a chemical transmitter that causes a specific set of symptoms including flushing, diarrhea, weight loss, heart palpitations etc. This set of symptoms is called “carcinoid syndrome.” Carcinoid tumors can also arise in lung, thymus, stomach, duodenum, small bowel, colon and rectum. Less than one percent of carcinoid tumors originate in the pancreas.

True cysts of the pancreas
True cysts are very rare and are defined pockets of fluid collection around the pancreas that are lined by epithelium. They are not the most common type of cysts of the pancreas. Pseudocyst or “false” cysts of the pancreas are lined by granulation tissue and often occur as sequelae of acute or chronic pancreatitis. These cysts often contain a mixture of pancreatic juices mixed with old blood that had leaked out from the ruptured or inflamed pancreas.
 
  • The most common forms of true cycts are mucinous and serous cystadenomas.
  • The other infrequent cystic tumors include papillary cystic tumors, cystic neuroendocrine tumor, cystic teratoma, lymphangioma, hemangioma, and paraganglioma.

 

Mucinous type are the most common cystic pancreatic neoplasms and are often seen in women over the age of 60. Abdominal pain, weight loss, early satiety, nausea and vomiting are among the most frequently reported symptoms. But most are asymptomatic and are discovered incidentally during a routine check up when a scan is ordered. While some may be benign, a good percentage of these may be premalignant or malignant and therefore need thorough evaluation.

At City of Hope, our team of surgeons work closely with the gastroenterologists to devise an individualized plan based on the CT or MRI scan and the ERCP with an EUS. Cystic fluid is usually aspirated when possible and an analysis of the fluid to rule out malignant potential is done in the laboratory.

Pancreatic Symptoms

Pancreatic cancer risk factors

Many factors can contribute to the risk of developing pancreatic cancer, including:
 
  •     History of chronic pancreatitis
  •     Cigarette smoking
  •     Long-standing diabetes
 
Certain rare hereditary conditions can also be associated with pancreatic cancer, however the majority of pancreatic cancers are not hereditary.
 
Pancreatic cancer symptoms
Pancreatic cancer is sometimes called a "silent disease" because early pancreatic cancer often does not cause symptoms. But, as the cancer grows, symptoms may include:
 

 

  • Pain in the upper abdomen or upper back
  • Yellow skin and eyes, and dark urine from jaundice
  • Weakness
  • Loss of appetite
  • Nausea and vomiting
  • Weight loss

These symptoms are not sure signs of pancreatic cancer. An infection or other problem could also cause these symptoms. Only a doctor can diagnose the cause of a person's symptoms. Anyone with these symptoms should see a doctor so that the doctor can treat any problem as early as possible.

Diagnosing Pancreatic Cancer

The following tests and procedures may be used to diagnose and stage cancer of the pancreas:
 
  • Physical exam and history
  • Chest X-ray
  • Biopsy
    Tissue samples are examined under the microscope to determine what types of cells are present.
  • CT or CAT (computerized axial tomography) scan
    The CT scan is the primary study used to diagnose and stage pancreatic tumors. This procedure uses a computer connected to an X-ray machine to obtain detailed pictures of areas inside the body. A dye may be used to help visualize organs or tissues more clearly.
  • MRI (magnetic resonance imaging)
    MRI creates a series of detailed pictures of areas inside the body, using the combination of a powerful magnet, radio waves and computer imaging.
  • PET (positron emission tomography) scan
    This scan is used to identify malignant cells even before an actual “lump or bump” can be detected in a physical exam, or on CAT or MRI scans. A small amount of radionuclide glucose (sugar) is injected into a vein prior to the scan. Because cancer cells divide more frequently than normal cells, they take up more glucose than normal cells and appear brighter in the scan.
  • Endoscopic ultrasound
    A thin, lighted tube called an endoscope is inserted into the body. The device emits ultrasound waves that create images of internal organs and structures.
  • Laparoscopy
    This surgical staging procedure is used to examine internal organs. An incision is made in the abdominal wall and a thin, lighted tube called laparoscope is inserted into the abdomen where various organs can be visualized by the surgeon, and tissue samples and lymph nodes can be removed for biopsy .
  • Endoscopic retrograde cholangiopancreatography (ERCP)
    This procedure is an X-ray examination of the bile ducts which is aided by a video endoscope. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be better visualized to determine if there has been a blockage or other abnormality.
  • Percutaneous transhepatic cholangiography (PTC)
    PTC is used to X-ray the liver and bile ducts in cases where an ERCP is not possible. A thin needle is inserted through the skin, below the ribs and into the liver. Dye is injected into the liver or bile ducts, and an X-ray is taken. If a blockage is found, a stent may be left in the liver to drain bile into the small intestine, or alternatively, into a collection bag outside the body.
 

Pancreatic Cancer Treatment Options

In situations where the cancer is contained within an organ (localized), surgery may be used to remove the cancerous tissue as well as a portion of tissue surrounding the area. In cases where a tumor cannot be removed by surgery (inoperable), other strategies may be considered to help relieve symptoms.

Department of Surgery
When appropriate, minimally invasive surgical procedures may be used to treat pancreatic cancer. These techniques require only small incisions to accommodate thin, flexible laparoscopic instruments.

Potential benefits of minimally invasive surgeries include:

  • Less blood loss, pain and visible incisions
  • Shorter hospital stays and recovery time
  • Fewer post-operative complications
  • Quicker return to normal activities

In addition to traditional surgical techniques, City of Hope  surgeons are highly skilled in robotic-assisted surgery, using the most advanced da vinci S Surgical System. This system can achieve excellent results in complex lung operations . A surgeon directs and controls the movements of a specially designed robot, equipped with a camera and miniature surgical tools. At the same time, a sophisticated computerized imaging system provides real-time three-dimensional views of the surgical area, with better visualization than can be achieved with the surgeon’s eye alone.
 
Surgical Procedures

 

  • Pancreaticoduodenectomy (Whipple procedure)
    This procedure involves removing the head of the pancreas along with the bile duct and the upper part of the intestine. During the surgery, the bile system, intestine and pancreas are reconstructed with tissue from the intestine. A portion of the pancreas is preserved to produce digestive juices and insulin.
  • Total pancreatectomy
    This operation removes the pancreas, part of the stomach and small intestine, the common bile duct, gallbladder, spleen and nearby lymph nodes. A restricted diet, supplemental digestive enzymes and insulin will be necessary for patients who undergo this procedure.
  • Distal pancreatectomy
    Tumors of the tail of the pancreas are often removed by performing a procedure known as a distal pancreatectomy. This may include removal of the spleen, which is located near the tail of the pancreas.
  • Central pancreatectomy
    Tumors of the main body of the pancreas can be treated using a central pancreatectomy, a complex operation that allows the removal of the tumor while preserving most of the pancreas. This minimizes the risk of developing diabetes and problems digesting food.

Palliative Surgery Options
In some cases, surgical removal of a tumor is not recommended. This includes cases in which a pancreatic cancer has spread beyond the pancreas itself, and where tumors are affecting the blood flow to the liver or intestine. In such cases, the following procedures, called “palliative surgery,” are not curative but may be considered to relieve symptoms:
  • Surgical biliary bypassIf a tumor is blocking the bile system and causing bile to build up in the liver, a biliary bypass may be performed. The gallbladder or bile duct is attached to the small intestine to bypass the blocked area, which helps to relieve the buildup of bile and accompanying jaundice.
  • Stent placementIf a tumor is blocking the bile duct, a stent may be inserted to drain the bile that has built up in the area. The stent may bypass the blockage and drain the bile into the small intestine, or it may drain outside the body. Stents can be placed during surgery or percutaneous transhepatic cholangiography, or in an endoscopic procedure.
  • Gastric bypassIf a tumor is blocking the flow of food from the stomach, the stomach may be reattached to the small intestine, to make it easier to eat normally.

Radiation Therapy
Radiation therapy uses high-energy X-rays and other types of radiation to kill cancer cells. City of Hope was the first in the western U.S. to provide treatment for pancreatic cancer using the Helical TomoTherapy System. This innovative system couples three-dimensional imaging with innovative intensity-modulated radiation therapy to target the tumor with extreme precision. The system not only provides more effective and potentially curative treatment, it reduces unwanted exposure of normal tissues and reduces potential complications.

Chemotherapy
Chemotherapy drugs destroy cancer cells by interfering with their growth and multiplication. Some chemotherapies involve an infusion of drugs into a vein or central line. City of Hope actively conducts research into finding more effective drug treatments for pancreatic cancer.

Pain Management
Pain can occur when the tumor presses on nerves or other organs near the pancreas. When pain medicine is not enough, treatments may be given to reduce pain coming from nerves in the abdomen. Medicine may be injected into the area around affected nerves, or nerves can be cut to block the transmission of pain signals. Radiation therapy may also be used with or without chemotherapy to shrink tumors, which can help relieve pain.

Nutrition Management
Surgery to remove the pancreas may interfere with the production of pancreatic enzymes that help to digest food. As a result, patients may have problems digesting and absorbing nutrients into the body. To prevent malnutrition, medicines may be prescribed to replace these enzymes

 

 

Pancreatic Cancer Resources

All of our patients have access to the  Sheri & Les Biller Patient and Family Resource Center, which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.

Additional Resources
 
PanCAN (Pancreatic Cancer Action Network)
Phone (toll-free): 877-272-6226
E-mail:info@pancan.org
PanCAN is a nonprofit organization founded by family members of individuals lost to pancreatic cancer. The organization works to focus national attention on the need to find a cure for pancreatic cancer, and provides public and professional education embracing the urgent need for more research, effective treatments, prevention programs and early detection methods.
 
American Cancer Society
Phone: 800-ACS-2345
866-228-4327 for TYY
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.
 
National Comprehensive Cancer Network (NCCN)
Phone: 888-909- NCCN (6226)
The National Comprehensive Cancer Network (NCCN), an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.
 
The National Pancreas Foundation
Phone (toll free): 866-726-2737
The mission of the National Pancreas Foundation is to support the research of diseases of the pancreas and to provide information and humanitarian services to those people who are suffering from such illnesses.

U.S. Dept. of Health & Human Services National Institutes of Health (NIH)
301-496-4000
301-402-9612 for TYY
The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health & Human Services.
 

Pancreatic Cancer Research and Clinical Trials

City of Hope has long been a leader in cancer research, including pancreatic and bile duct cancers. Multiple clinical trials are ongoing, offering our patients access to new and advanced treatments involving chemotherapy, radioimmunotherapy and radiation.
 
Through our research programs, patients can gain access to promising new anticancer drugs and technologies that are not available to the general public. As a patient at City of Hope, you may qualify to participate in a test of these new investigational therapies.
 
To learn more about our clinical trials program and specifically about clinical trials for pancreatic cancer, click here.

 

 

Pancreatic Cancer Team

Support This Program

It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.

For more information on supporting this specific program, please contact us below.

Joe Komsky
Senior Director
Phone: 213-241-7293
Email: jkomsky@coh.org

 
 
Pancreatic Cancer Care
City of Hope, as a Comprehensive Cancer Center, actively conducts research into finding more effective treatments for pancreatic cancer.
 
Treatments and Clinics
A national leader in cancer treatment and prevention, City of Hope is steadfast in its drive to offer more positive outcomes to patients everywhere. Our research innovations become advances in patient care without delay, because people fighting cancer need better options – now.

To make an appointment for yourself, a family member or a friend, please complete and submit our Become a Patient Request Form, or call City of Hope at
800-826-HOPE (4673).
The Sheri & Les Biller Patient and Family Resource Center embodies the heart and soul of City of Hope’s mission to care for the whole person.
Clinical Trials
Our aggressive pursuit to discover better ways to help patients now – not years from now – places us among the leaders worldwide in the administration of clinical trials.
 
Situated just northeast of Los Angeles, City of Hope combines the best science and the most innovative and highly compassionate patient care. Stretched across more than 100 acres in the City of Duarte, lushly landscaped gardens surround state-of-the-art facilities.
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