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Pancreatic Cancer

Pancreatic cancer is a rapid malignant tumor that interferes with the organ’s production of digestive enzymes and hormones. The anatomy of the gland involves the involvement in the tumor process of the stomach, behind which it passes. Metastases in the lymph nodes of the gates of the liver lead to a violation of the outflow of bile, which is manifested by jaundice.

Pancreatic Cancer Stages

Unfortunately, stage 1 cancer of this localization is very seldom detected. The disease is known for its high aggressiveness, the rapid spread of metastases, and even the simultaneous formation of metastases and a node in the gland.

It is believed that at the stage of intraepithelial neoplasia, benign cells are able to leave the organ and disperse throughout the body, so that having received a genetic signal for malignancy, they begin to form metastases even before the clinically determined primary cancer. Such a theory has arisen due to the identification of a significant number of patients with a common disease and a small primary tumor, or no tumor at all.

  1. Stage I is the formation of up to 2 cm and more, but without leaving the glandular tissue and without affecting the lymph nodes.
  2. Stage II — the node can go beyond the gland, but there are no cancer cells in the lymph nodes or the second option is that the primary lesion of any size is of any size.
  3. Stage III — cancer has spread to the large vessels of the abdominal cavity and lymph nodes.
  4. Stage IV — there are distant metastases, the size of the primary education and lymph nodes are not important.

Pancreatic cancer is a rapid malignant tumor that interferes with the body’s production of digestive enzymes and hormones. The anatomy of the gland involves the involvement in the tumor process of the stomach, behind which it passes. Metastases in the lymph nodes of the gates of the liver lead to a violation of the outflow of bile, which is manifested by jaundice.

Pancreatic Cancer Stages

Unfortunately, stage 1 cancer of this localization is very seldom detected. The disease is known for its high aggressiveness, the rapid spread of metastases, and even the simultaneous formation of metastases and a node in the gland.

It is believed that at the stage of intraepithelial neoplasia, benign cells are able to leave the organ and disperse throughout the body, so that having received a genetic signal for malignancy, they begin to form metastases even before the clinically determined primary cancer. Such a theory has arisen due to the identification of a significant number of patients with a common disease and a small primary tumor, or no tumor at all.

  1. Stage I is the formation of up to 2 cm and more, but without leaving the glandular tissue and without affecting the lymph nodes.
  2. Stage II — the node can go beyond the gland, but there are no cancer cells in the lymph nodes or the second option is that the primary lesion of any size is of any size.
  3. Stage III — cancer has spread to the large vessels of the abdominal cavity and lymph nodes.
  4. Stage IV — there are distant metastases, the size of the primary education and lymph nodes are not important.

Symptoms of pancreatic cancer are often mistaken for exacerbation of chronic pancreatitis, which has either worried the patient for a long time, or is considered to be secretly leaking and suddenly activated. But not only therefore, the majority of the disease is detected in the advanced stage, there are biological reasons for this.

Where Does the Neoplasm Localize?

Pancreatic cancer in 95% is adenocarcinoma, but this is not the only cellular variant, the remaining seven malignant tumors account for only 5%.

It occurs in any part of the organ, in two thirds — in the head, in every sixth patient — in the body and in every 20th patient in the tail. In some cases, it is not possible to find out where the tumor grew from because of its large size, but the average diameter of a cancer tumor during primary diagnosis rarely exceeds 3 centimeters, and there are almost always lymph node metastases and often in other organs.

Symptoms Caused by Pancreatic Cancer

These are the initial manifestations of the disease, their intensity depends on the size of the node and the involvement of other nearby organs and vessels in it.

Pain — the most common symptom caused by the spread of cancer along the nerve trunks in the form of a clutch — perineural invasion. With the growth of education appear pain in the epigastric region and hypochondria. When the cancer engulfs the retroperitoneal nerve plexus, the pain gives way to the back and increases as you lean forward. The intensity of pain in the evening and at night increases, it is aggravated by the concomitant inflammation of the parenchyma of the gland, the compression of the bile ducts and the spasm of the vessels involved in the pathological process.

With damage to the body and tail, glandular tissue function is disturbed and symptoms of diabetes mellitus can develop, thrombi are formed in abundance, including against the background of inflammation of the venous trunks, and immune deficiency develops.

The patient loses weight, weakness increases, fatigue due to «poisoning» by the increasing tumor mass increases.

Symptoms from Other Organs

The gland intimately adheres to the liver, stomach and duodenum, with the growth of the cancer node they are involved in the process, which is manifested by the symptoms of their inflammation and compression. These are pain and disorders of the functions of the digestive tract in the form of belching and anorexia. Probably loose stools and constipation, all against the backdrop of flatulence. The compression of the output section of the stomach leads to nausea and vomiting eaten, the formation of the tail can partially block the lumen of the small intestine.

The compression of the bile duct is accompanied by inflammation, hence the fever. The temperature reaction may be caused by gland tissue that breaks down due to the enzymes present in the cells.

A characteristic symptom of the disease is a sharp decrease in weight due to digestive disorders and a lack of enzyme synthesis. Anemia develops.

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The Undoubted Causes of Pancreatic Cancer

The causes of pancreatic cancer will help uncover ways to prevent the disease, in which the incidence slightly exceeds the mortality rate. This is a male tumor, women suffer three times less often and at a much more solid age. Diagnosis in Europe is better, and therefore the incidence is higher.

To date, no single root causes of the disease have been identified, but some pathological conditions significantly increase the risk of pancreatic malignant disease.
Tobacco smoking doubles the risk of a malignant tumor of the gland; in every fourth person who smokes, tobacco becomes the main cause of the disease. The probability of pancreatic cancer is directly dependent on the duration of the bad habit and the volume of daily cigarette servings.

The second proven cause of morbidity is type 2 diabetes, not congenital, but acquired. In a diabetic, the risk of a malignant tumor is increased by 60% and after the 50th anniversary of every 100th diabetic, pancreatic cancer is diagnosed.

The third reason is chronic pancreatitis of any etiology, it increases the probability of tumor pathology by 20 times. Inflammation leads to intraepithelial neoplasia, and for most patients this is a direct route to cancer. With neoplasia, the cells divide too quickly, losing the ability to recover if damaged, the slender architectonics of the glandular tissue is lost. The same proliferative processes in the aggravated form occur in a malignant neoplasm.

Heredity as a Cancer Cause

Every 50th patient with chronic pancreatitis has a hereditary form of inflammation of the gland, with it the probability of a malignant regeneration of the pancreas increases by 50 times, and the disease is diagnosed in four out of ten people suffering from pancreatitis. If with this genetic background, and even smoke, then a malignant neoplasm will appear at a younger age. And the gene that is unable to stop the synthesis of the enzyme trypsin, produced in excess and causing the digestion of pancreatic cells, which leads to the formation of neoplasia, is to blame.

Every 20th patient with pancreatic cancer has a hereditary tumor. With a parent suffering from cancer, the probability of his descendant becoming ill is doubled when both parents are sick — six times, if three first-line relatives are sick — 30 times. But what genes regulate family transmission, while not exactly determined.

In the US, the incidence of pancreatic oncopathology in African Americans is half that of whites, which may be due to genes.

Suspicious but Not Proven Risk Factors

Animal protein rich and poor in plant components nutrition has long been suspected as the cause of pathology, but in clinical studies have not produced conclusive evidence. It is believed that the effect of meat is exacerbated by coffee, but no scientific basis was found for this hypothesis.

Nevertheless, among those who came from regions with a low incidence of immigrants who live long enough in a country with a high incidence, the possibility of becoming ill is compared with the local population. And the reason — the inevitable change in diet.

It is assumed that pathology is associated with obesity, but for the time being this is also an unconvincing hypothesis.

Infectious diseases also contributed to the causes of pancreatic neoplasms, by analogy with the fundamental role of the hepatitis virus in the initiation of liver cancer. But for the development of a pancreatic tumor, the role of Helicobacter pylori infection has not yet been proven.

There is an assumption that for the pancreas the removal of the stomach or gallbladder does not pass without a trace.

Diagnosis of pancreatic cancer should confirm or reject the malignant nature of the disease, find out its prevalence and exact localization in the gland. If there is an unconditionally operable tumor, verification — morphological confirmation of cancer can be performed during surgery.

What Pancreatic Cancer Diagnostics is Necessary?

The pancreas is available for examination by ultrasound, there are not very well visible tumors in the tail, because they are blocked by other hollow organs of the gastrointestinal tract. The large fatty tissue of the abdominal wall and cavity, which is typical for men, and intestinal gas formation prevent the examination. Ultrasound diagnostics reveals neoplasm over a centimeter.

A neoplasm smaller than a centimeter reveals a combined diagnostic method, endoscopic ultrasound, when an inside optics scan and an ultrasound scan are performed simultaneously. Moreover, the gland can be examined both from the stomach with the duodenum, from the biliary or pancreatic duct and the abdominal cavity during laparoscopy. Endosonography allows to take material for microscopy from suspicious formation with a thin needle.

Good prospects for the diagnosis of pancreatic pathology with MRI with contrast and X-ray CT (CT), and spiral CT with angiography will clearly reveal the relationship of cancer with nearby large vessels.

When is Diagnostics with Biopsy Necessary?

A biopsy allows taking a piece of tumor tissue for examination to eliminate all doubts about the nature of the tumor. If an operation is planned, then the preoperative biopsy can be waived and the material for microscopy can be taken already during the intervention. When a tumor is not removed for chemotherapy or radiation, it is necessary to accurately diagnose the malignant process, so a biopsy is required.

In addition, in 5% of cases a malignant tumor in the pancreas has a structure other than cancer and requires a different treatment. Unfortunately, none of the diagnostic methods can give an exact answer «what is it», except for research under a microscope. Biopsy of the pancreas is performed under the control of ultrasound or CT and does not pose a danger to the patient.

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Additional and Clarifying Diagnostics

Esophagogastroduodenoscopy (EGDS) is always carried out, as it accurately indicates the involvement of the duodenum in the tumor process, which is very likely, because the pancreas is located in close proximity.

Compound diagnostic study under the abbreviation ERCP means the introduction of contrast into the ducts during endoscopy, it is useful in the absence of morphological confirmation, because it allows to distinguish cancer from pancreatitis, but is not at all free from complications.

With ambiguities in the interpretation of the CT, the situation can be resolved by angiography, an x-ray with vascular contrasting.

Laparoscopy may be required in cases of suspected metastatic peritoneal lesion and ascites — the formation of abnormal fluid in the abdominal cavity.

Pancreatic Cancer Markers

In pancreatic cancer, CA 19–9, CEA, CA 50, CA 72.4 and CA 242 may increase, only the first two are of practical importance. True, these markers increase in other diseases, so their level can be used to assess the results of treatment and the course of the process with an initial increase in concentration. If during the initial diagnosis the level of the marker in the patient was normal, then monitoring is doubtful.

The normal value of CA 19–9 is below 37 U / l. It is noted that with a high prevalence of a tumor, its concentration is higher than with a small amount of cancer.

Cancer embryonic antigen (CEA) normally does not exceed 2.5 ng / ml in non-smokers, the smoker is slightly higher, but not more than 5 ng / ml. When cancer is widespread, a directly proportional relationship is noted — the concentration of CEA is higher.

Jaundice in pancreatic cancer

A tumor that has reached a significant size causes jaundice due to compression of the liver ducts, itching of the skin appears, the urine darkens, and the feces become light.

Nausea increases, appetite completely disappears, vomiting, dry mouth, diarrhea appear. Ulcers may appear on the skin, more often pustular lesions occur. The patient is quickly exhausted, pronounced loss of strength.

Treatment for obstructive jaundice

Jaundice is evidence of a pronounced dysfunction of the liver, which significantly worsens the patient’s condition and leads to death, therefore, if there is such a complication of pancreatic cancer, bile outflow is first restored. How this will be done is determined by the length of the narrowing of the bile duct, the ability to remove the cancerous gland and the patient’s condition.

To remove bile, one of three manipulations is performed:

  • The least complicated and with a smaller number of complications is puncture through the skin of the bile ducts and the installation of drainage — a tube that removes the bile that is formed.
  • Drainage of the bile duct during endoscopy with the installation of the stent often causes serious complications and after some time dangerous recurrence of jaundice, so it is performed before a radical operation on the pancreas.
  • The most complex surgical method with the formation of anastomoses — the connections of the bile ducts with the gastrointestinal tract is also not free from complications.

Operable Cancer Treatment

The tactics of treating pancreatic cancer depends on the stage and form of the tumor. Complete removal of a tumor-modified part of the gland or of the whole organ is considered radical. There are different kinds of pancreas resection but with a neoplasm in the head, the glands more often resort to complete removal — pancreathectomy.

After the surgical stage, multi-course prophylactic adjuvant chemotherapy is mandatory. Preferably the use of gemcitabine, as the least toxic in comparison with other effective drugs. To detect sensitivity to it, analysis of the hENT1 protein is performed; if there is no protein, the drug will not be delivered to the tumor cell, therefore chemotherapy with other drugs is performed.

Tactics for major pancreatic cancer

Learn about modern approaches to cancer therapy.

With dubious prospects of removal or uncertainty about the complete radical nature of future intervention, chemotherapy is performed at the first stage, using the same gemcitabine. It is possible to join the drug treatment and irradiation of the gland. After 2–3 months of therapy, a control examination is carried out; if the tumor has decreased, an organ resection is performed. After surgery, chemotherapy continues, but its nature is prophylactic.

Therapeutic approaches to the metastatic stage

The text is written based on NCCN (National Common Cancer Network).