Pancreatic Cancer Symptoms, Diagnosis and Treatment The cancer of the pancreas or carcinoma is a pancreatic cancer tract. the tumors of neuroendocrine pancreas are another type of cancer, whose presentation is radically different. they are presented in the article neuroendocrine tumor.
Incidence and mortality of pancreatic cancer rate for 100 000 people
Impact
Mortality
CountryHFHFFinland13,09,912,8 Sweden9,8 Switzerland11,37,611,87,8 European Union9,76,510,77,3 France8,04,2 Luxembourg8,3 Portugal4,9It affects slightly more often men than women with incidence increasing with age (peak incidence at 75 years for men, 80 years for women). in older ages the rate is high e.g. 65 and above, the pancreatic cancer in Geneva about 5% and 6.5% respectively of male and female patients with cancer (at the front for men from lung cancer with 22.4% and for women the breast cancer with 19.8%). Pancreatic cancer is responsible for 2500 deaths per year in France.
Risk factors:
Contributing factors are a known pancreatitis chronic (post-alcoholic, tropical, or as part of a cystic fibrosis) or smoking. the obesity is another risk factor.
Familial forms exist four but genes involved remain unknown.
Symptoms
The development of cancer at the pancreatic head (60-70% of cases) creates a barrier biliary responsible for a rapid expansion of the gallbladder, a jaundice (for retention bladder) and pruritus (itching) caused by jaundice.
If cancer develops in the tail of the pancreas (7%), the clinical picture is dominated by transfixing epigastric pain (radiating to the loin), accompanied by a mass epigastric.
Other signs of cancer are sometimes significant alteration in general health (asthenia, anorexia, and weight loss), high occlusion by compression or invasion of the stomach or duodenum, a hepatomegaly irregular secondary to metastatic liver.
Finally, the destruction of the pancreas can cause pancreatic insufficiency (malabsorption and diarrhea) and endocrine (diabetes).
Diagnosis
The diagnosis rests on biopsy, pancreatic or liver metastases. this biopsy can be performed by trans-dermal, during a fiber optic gastro-duodenal, or during surgery.
An assay of CEA and CA 19-9 may refer to an adenocarcinoma; hormonal assays may characterize an endocrine tumor.
Imaging
The ultrasound is the gold standard to visualize the pancreas, an organ located deep in the abdomen and the observance of which is hampered by the interposition of bowel gas. this review remains frequent first-line exploration of abdominal pain. it allows, through this, to discover a significant number of tumors of the pancreas. its sensitivity is 75% lower than the scanner5. a normal ultrasound does not eliminate pancreatic cancer.
The scanner with abdominal injection of contrast medium iodine remains the gold standard. it allows also better assessing the local extent and existence of metastases, particularly in the liver and thereby determining the operability.
The MRI has a sensitivity intermediate between the scanner and ultrasound.
The endoscopy may insert a tube into the duodenum until the emergence of the pancreatic duct. Injection at this level of contrast with radiography allows a CHOLANGIOPANCREATOGRAPHY. this examination may detect a narrowing occasionally to one of the channels, which may reflect a compressive tumor. this review, however, a low-level performance diagnosis. By coupling the endoscope with an ultrasound probe, gives an ultrasonography. this review has a very good sensitivity for detecting tumors, even small sizes7. this examination also allows directed biopsy.
The goal is to visualize the pancreatic tumor, and seek lymph node metastases, liver, or peritoneal. we also study the relationship with the portal vein.
Pancreatic cancer can take many different forms: – in 90% of cases, reached the head of the pancreas – 10% of cancer cases correspond to the body or tail of the pancreas.
The CA 19.9 marker is the most interesting, primarily in assessing the effectiveness of treatment (rate collapses) and the detection of recurrence (rate rises again). it is, cons, little used in routine screening, its elevation is not specific for pancreatic cancer.
The pancreatic adenocarcinoma histology may have several forms:
There are cystic tumors of the pancreas that can degenerate (cystadenocarcinoma) or tumors of the excretory ducts of the pancreas (IPMT).
Differential Diagnosis
There are cancers of the endocrine pancreas (very rare twenty times less common than exocrine), revealed by their hormonal secretion, thus giving: insulinoma, glucanome, VIPomas … Tumors, often very small, are difficult to locate and resect. An ampulloma (tumor of the ampulla of Vater) can give symptoms similar to adenocarcinoma of the head, but it is a tumor of the bile ducts, much better prognosis. Similarly the lower bile duct cholangiocarcinoma may be confused with pancreatic cancer. the prognosis is very bleak.
Classifications
1. TNM classification (UICC 2002)
2. T (tumor)
3. Tx Insufficient information to classify the primary tumor
4. T0 No evidence of primary tumor
5. Tis Carcinoma in situ
6. T1 Tumor limited to pancreas <2 cm in greatest diameter
7. T2 Tumor limited to pancreas,> 2 cm in greatest diameter
8. T3 Tumour extends directly to any of the following organs: duodenum, bile duct, peripancreatic tissue.
9. T4 Tumour extends directly to any of the following organs: stomach, spleen, colon, adjacent large vessels
N (Regional Lymph Nodes)
10. Nx Insufficient information to classify the regional lymph nodes
11. N0 No regional lymph node metastasis
12. N1 Regional lymph node
13. N1a invasion of a single node
14. N1b Metastasis in multiple lymph
M (Distant metastasis)
15. Mx Insufficient information to classify distant metastases
16. M0 No distant metastasis
17. M1 Presence of metastasis (s) remotely
Prognostic Factors
Pancreatic cancer is a tumor with very poor prognosis.
When the diagnosis of pancreatic cancer is increased, the chance of survival at 5 years is 1 to 4%. twenty percent of patients operated on are fully alive at 5 years. in contrast to patients unrespectable and metastatic median survival was 6 months and 5-year survival is zero.
Treatment
Given the poor prognosis, it is legitimate to consider aggressive treatment for patients in good general condition for which surgery is best possible. when the patient is inoperable (bad condition, lesion unrespectable metastases) the quality of life must be preserved as long as possible. Supportive cares were then predominant.
Therapeutic Approaches
Surgery
The surgery was the first-line treatment for a tumor not exceeding a certain size and with no metastasis or too intimate contact with the portal vein, but the location of this tumor because it is not easily accessible (many veins behind). moreover, recent protocols show an advantage to pursue a radio-chemotherapy pre-and postoperatively in selected cases. there section is possible only in 20% of cases. Loco regional relapse occurs, however, in 70 to 80% of cases. the surgical resection of the pancreatic head (cephalic duodeno-pancreatectomy) is heavy, due to venous reports, tracts, and bile. it may not be offered to a patient in good general condition, in the absence of respiratory or cardiac defect. for tumors of the tail of the pancreas, surgery is the reference spleno-pancreatic tail.
In the case where no curative surgery is possible, we prefer, if necessary, palliative surgery to treat the symptoms, allowing the flow of bile and food bowl:
Double bilio-digestive. These diversions are more often performed endo-scopically, with placement of stents and duodenal bile.
Radiotherapy or Chemo Radiotherapy
In cases of advanced tumor, the radio-chemotherapy is used either after surgery or in lieu thereof. Radiation therapy delivers 45-50 Gy in 5-6 weeks and is associated with 5-FU continuous low dose. Used after surgery, experiencing “adjuvant” radio chemotherapy allows a reduction in local recurrence but the gain in survival remains low. this strategy is controversial at present.
Chemotherapy
The chemotherapy is used mainly in the metastatic setting, in addition to symptomatic treatment (bypass surgery, nutrition, analgesics, psychological support). the products are mainly used gemcitabine9, and to a lesser extent, 5-FU, cisplatin andoxaliplatin.
In metastatic disease, the palliative effect is demonstrated for the combination of gemcitabine and 5-FU and cisplatin. in the adjuvant setting, that is to say after curative surgery, chemotherapy reduces the risk of recurrence or delaying it.
The chemotherapy protocols validated in pancreatic cancer are:
Gemcitabine
Cisplatin – sLV5FU2
GEMCEA
GemOx
Therapeutic strategies presented here are based on the repository of the French Federation of Digestive Oncology, 2005. Modes of treatment may vary from one country to another and from one region to another.
Resectable tumor
The small tumors in patients are able to withstand a surgical resection with curative intent. the standard treatment is surgery with curative type duodeno-cephalic pancreatectomy for tumors of the pancreas head and caudal spleno-pancreatectomy for tumors of the pancreatic tail. Adjuvant treatment depends on the quality of resection.
In case of complete resection with adequate margins (R0 resection), adjuvant chemotherapy include LV5FU2 for 6 months.
If microscopic incomplete resection (R1) or macroscopic (R2) will include either the adjuvant chemotherapy of 5FU-cisplatin type or gemcitabine for six months or a radio-chemotherapy.
Unresectable Tumor
If the tumor is not resectable at the outset but it is likely that treatment with radiotherapy or chemotherapy will reduce the tumor enough to make it operable, it is possible to begin treatment, said “neo-adjuvant ‘by a combination radio-chemotherapy (cisplatin with 5FU) and then reassess the operability of the lesion. in one third of cases, curative surgery may be prolonged, leading to a more prolonged survival10. If the lesion is permanently inoperable, there is a choice between chemotherapy alone, a combination radio-chemotherapy and chemotherapy followed by an association of radio-chemotherapy for patients whose tumors decreased under chemotherapy.
Metastatic tumor
1st line: 5FU-cisplatin or gencitabine 2e online: gencitabine, or 5FU-cisplatin GemOx according to the first line.
Author: Peter Norman
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