Pancreatic carcinoma

What is it?

The incidence of pancreatic cancer is increasing: it is the fourth leading cause of cancer death in humans.

Causes and risk factors

There are no specific risk factors other than cigarette smoking. Progression is often rapid, and there is a tendency for metastases to form.

Therefore, the prognosis in many cases is quite serious. However, the rapid development of research in this field may lead in the next few years to new drugs or treatments that improve the outcome of the disease.

Which are the symptoms?

The diagnosis of this tumor is often made late because the symptoms are unclear and uncharacteristic. The clinical picture is characterized by:

  • unclear pain in the upper abdomen;
  • lack of appetite;
  • weight loss;
  • jaundice (yellowing of the skin and eyes);
  • pain in the back or lower back, radiating to the stance.

How is it diagnosed?

The following tests are performed to determine the pathology:

  • specialist examination by a general surgeon or oncologist: this allows evaluation of the pathology and determination of the diagnostic and therapeutic course;
  • dosage of tumor markers: in particular, CA 19-9 is increased in the presence of a tumor;
  • ultrasound, ecoendoscopy, computed tomography and/or magnetic resonance imaging: their purpose is to detect the presence of a tumor, determine its relationship with surrounding structures (and therefore the possibility of surgical intervention) and exclude the presence of metastases in other organs (in particular, in the liver);
  • pancreatic needle aspiration (under ultrasound or ecoendoscopic guidance): it allows to determine the type of tumor when it is a tumor that cannot be removed.

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How is it treated?

If the tumor is localized in the pancreas and does not infiltrate the surrounding vascular structures, surgical removal is usually recommended, but is only possible in 20-30% of cases.

Surgery on the pancreas is delicate and technically difficult because of the deep location of the organ in the abdominal cavity and its loose consistency. Therefore, the results vary greatly and depend largely on the experience of the medical team performing the surgery.

The goal of the surgery is to remove the tumor tissue.

When the tumor is localized in the head of the pancreas, not only the head of the pancreas but also the duodenum, the distal choledochus, and the gallbladder must be removed for anatomical and oncological reasons. This surgery is called a duodenocephalopancreasectomy, it lasts an average of 5-8 hours, and includes:

  • section of the duodenum, choledochus, pancreas, and first diginoid loop;
  • block removal of the distal pancreas-duodenum-choledochus head;
  • connection of the diginoid loop to the residual pancreas, residual choledochus and the first portion of the duodenum.

If the tumor is located in the body or tail of the pancreas, its removal is achieved by distal pancreasectomy surgery. The operation lasts on average 2-4 hours, includes dissection of the pancreas at the level of transition of the head into the body and removal of the left half of the organ, usually together with the spleen, which is anatomically located in close proximity to the tail of the pancreas. No other sutures or reconstructions are required.

After surgery, due to the high risk of local (in the pancreas) or distant (in other organs) recurrence, additional chemotherapy and radiotherapy is recommended. Subsequently, a visit to an oncologist for planning a postoperative treatment program is indicated, as well as a possible visit to an endocrinologist in the case of postoperative diabetes mellitus.

In other cases where surgery to remove the tumor is not possible, outpatient chemotherapy and/or radiotherapy may be given. Chemotherapy with gemcitabine-containing regimens is usually used, which in some cases allows removal of some localized tumors that were previously considered unresectable. Radiation therapy improves local control of the disease and is usually combined with radiosensitizing chemotherapy.

If the tumor causes symptoms such as jaundice or duodenal stenosis, endoscopic, surgical, or percutaneous radiological intervention is necessary.

In addition to drug therapy, usually performed by oncologists or therapists specializing in pain management, the method of neuroendoscopic guidance of the seliar plexus neurolysis has recently become widespread. This procedure can be performed during ecoendoscopy for staging and cytologic typing of pancreatic cancer, in one session, with the patient under deep sedation with anesthesia assistance. Compared with transcutaneous neurolysis, ultrasound-guided neurolysis has a lower risk of complications and good pain control, and has the advantage of reducing the side effects caused by opioid analgesics.

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