1) What are pancreas ? Where is it located?
The pancreas is a leaf shaped organ located in the back of the abdomen, behind the stomach, and in front of the vertebral column. It looks like a fleshy gland which is divided into tail, body and head. The bile duct, which is the last portion of outflow of bile from the liver, enters the pancreatic head before entering the duodenum (1st part of the small intestine).
Thus, any tumor or swelling in the head results in obstruction to the flow of bile into the duodenum and this ultimately causes jaundice (also known as obstructive / surgical jaundice). The spleen is located close to the tail of the pancreas. While some cancers occur in the head of the pancreas others occur in and around the terminal part of the common bile duct in close proximity to the duodenum and the pancreatic head (periampullary cancers). The two cancers though often used synonymously vary in terms of survival and overall prognosis.
2) Why have I developed pancreatic / periampullary cancer ?
Development cannot be attributed to any single factor. There are multiple factors, some of which are congenital and some acquired. The factors associated with development include diets rich in animal fat and meat, cigarette smoking, occupational exposure to certain chemicals like benzidine and naphthylamine, and sometimes, preexisting chronic pancreatitis. Persons with familial syndromes like ataxia telangiectasia, hereditary pancreatitis, familial multiple mole syndrome, etc. are also at an increased risk. However, patients can develop these cancers without any of these factors being present.
3) What are the symptoms of pancreatic cncer / periampullary cancer?
The symptoms depend on the location of the tumor. The tumors which are located in the region of the head of the pancreas or in the pancreatic head itself all tend to present early as they obstruct the bile duct. This manifests in the form of obstructive jaundice which includes yellowish discoloration of the eyes and skin, high colored urine, itching all over the body and pale, bulky stools. Also, there is a high chance that jaundice may reappear and disappear if the tumor is located in the head of the pancreas or periampullary. Pain is usually a late symptom and represents the involvement of surrounding structures that indicate advanced disease. The compression of the duodenum by a large tumor leads to vomiting. The tumors present in the tail and body, unfortunately, tend to present later as they are allowed to grow in size without any specific symptoms. Pain and a lump in the abdomen are the main features. Back pain, weight loss, loss of appetite, are also seen.
4) What investigations will I be subjected to ?
Triphasic computed tomography (CT) scan is the best investigation available. Triphasic computed tomography (CT) scan help in visualising the tumor as well as it find the spread of tumor to other organ in the abdomen. In some cases, the tumour cannot be well studied on CT scan due to its small size. Magnetic resonance cholangio-pancreatography (MRCP) can prove to be a valuable investigation is MRCP is used to suspect small tumor. A blood test known as serum CA 19-9 is a useful marker of cancer which help not only in diagnosis but also in detecting recurrence and metastasis after curative surgery in some patients. There are other investigations which decide the stage of the disease such as Liver function tests, X-ray of the chest etc.
5) The biopsy does not show cancer. Does this mean I do not have cancer?
No, Pancreas is located in the body where obtaining a biopsy is difficult. Cancer is with other conditions like pancreatitis which make diagnosis difficult for the pathologist. The decision of treatment is based on not just the biopsy but also the findings on CT scan and MRCP. So if the findings on CT scan or MRCP are suspicious we may have to proceed with surgery despite biopsy being negative. Final Hstopathology may not show cancer as there is a small chance. But in the majority of the cases one can predict the presence of malignancy with a fair degree of certainty.
What are the risk factors for kidney cancer?
Most patients who suffer from kidney cancer are above the age of 40 years. Males have a higher possibility of getting it as compared to females. Smoking , obesity and high blood pressure are known to increase the chances of getting kidney cancer. People on long term dialysis because of kidney failure are also prone to get this cancer. There is a condition known as von hippel lindau disease in which kidney cancer can run in families and be transmitted from one generation to another.
6) What stage is the cancer in?
The accurate staging of pancreatic cancer is based on histopathology and will be possible only after surgery. Pancreatic cancer can be broadly classified into two categories based on clinical and radiological findings :
Can removal of the entire kidney be avoided in case of cancer?
In recent years the procedure of radical nephrectomy is not considered necessary in all cases. In tumours which are small or located on one pole of the kidney only the affected part of the kidney is removed with a rim of normal kidney. This procedure is known as nephron sparing surgery. The procedure may not be suitable in all cases and also requires a higher expertise
A. Early cancer in which there is no disease found outside the pancreas
B. When the disease has come out of the pancreas and is invading the surrounding structures known as Locally advanced
C. When the disease has spread far from the pancreas known as Metastatic. Mostly this spread occurs in the liver
7) Now that I have been diagnosed to have pancreatic cancer, how will I be treated?
Mostly the treatment is based on the stage of the disease. Surgery will be done in early cancer. Chemotherapy is done in locally advanced tumors. If the cancer responds well and shrinks surgery may be offered after chemotherapy
In metastatic tumors the treatment is usually chemotherapy or symptomatic care
8) What is the surgery done for pancreatic cancer?
The type of surgery depends on the site, size and extent of the tumor.
The most commonly done surgery is Whipple's surgeryIn this surgery, the head of the pancreas, the duodenum, the gallbladder, and bile duct are removed and the remaining structures are joined together by 3 anastomosis, viz. pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy
Other procedures depending on the location include:9) Are there any alternatives for surgery?
In early pancreatic cancers, surgery is the only proven option. All other options are experimental.
10) The surgeon whom I consulted earlier advised me on stenting. Is this necessary?
Different surgeons have different policies regarding stenting. When the bilirubin is very high, stenting is done with the belief it is unsafe to operate. Some surgeons advice placing a plastic stent across the obstruction when the bilirubin is above a certain limit. Stenting causes inflammation in and around the area to be operated making surgery difficult. There are studies which show that major surgery can be done with bilirubin as high as 20. Stenting is advisable when bilirubin is very high (>20), the patient is nutritionally depleted, has symptoms like itching and when there is superadded infection leading to fever. (cholangitis).
11) How do I prepare for surgery?
The preparation is very similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anesthesthetist's advice regarding the continuation of medications if you are on any. A high protein diet is preferred to improve nutrition.
12) How major is the surgery? What are the possible complications?
The procedure is deemed as one of the most major operations in the abdomen was associated with very high complications and death in the past. Today, with the good availability of training and better supportive care, this surgery is performed at high-volume centres with a morbidity of 20% and a risk of death in less than 5% of persons. This means that if 100 people are operated on, less than 5 of them have a chance of death.
The complications of Whipple surgery (it involves the removal of a portion of the pancreas) include:Early
Late
13) How long do I have to stay in the hospital?
In an uncomplicated case hospital stay after surgery is usually 7-10 days. It can be longer when there are any other complications.
14) Will I need any further treatment after surgery?
The decision about adjuvant treatment is based on the final histopathology report which is available approximately 7-10 days after surgery. If any of the lymph nodes are positive and the general condition is good enough then it may be referred to the medical oncologist for chemotherapy.
15) What will be my survival after surgery? Are there any chances of the cancer coming back?
The survival differs greatly between periampullary cancers and cancer of the head of the pancreas. It will also depend on the stage of the disease. In patients with periampullary cancer who undergoes complete resection about 30 in 100 will survive and will be disease free at 5 years. The same figure falls to 5-10 in patients with cancer of the head of the pancreas. As of date there is no foolproof way of predicting which patients will have recurrence and which patient will not. With better surgical techniques the survival is now improving.
16) Are there any special precautions I can take to prevent cancer from coming back?
No, there’s no such proven precautions.
17) How frequently should I follow up after surgery?
Once the treatment has been done the patients will be advised to follow up once in 3-4 months in the first 2 years. Then the frequency will be reduced to once in 6 months for the next 2-3 years. Subsequent follow-up is needed once a year. During each follow up the patients will be asked to do certain blood tests especially CA19-9. The patients may also be advised to get an ultrasound of the abdomen done.