What is pancreatic cancer?

Around the pancreas, which is a 15-centimeter-long bifunctional gland located in the abdominal cavity; surrounded by stomach, small intestine, spleen and liver. The pancreas, which has two main functions called exocrine and endocrine, has two separate cell groups that enable it to fulfill these functions. It secretes the sap that helps in exocrine digestion and transmits it to the small intestine. Thus, carbohydrates, proteins and fats in foods are separated and stored as energy. The endocrine function tries to keep the glucose in the blood at a certain level by secreting glycogen and insulin hormones.

What causes pancreatic cancer?

Pancreatic cancer occurs when cells in the pancreas begin to multiply uncontrollably. Mostly, pancreatic cancer begins to form in the area of ​​exocrine cells surrounding the pancreatic ducts. Pancreatic cancer that starts in this region is an exocrine tumor, also known as adenocarcinoma. Endocrine tumor, which is a much rarer type of pancreatic cancer, starts in islet cells.

Types of pancreatic cancer

Pancreatic cancer consists of a rare species called "neuroendocrine" or "islet cell" that occurs in hormone producing cells, and "exoctrins", which is more common and occurs in ducts carrying pancreatic juice. Cystic tumors and acinar cell types are rarely seen in exoctrin pancreatic cancer. “Ampulla Vateri” tumors, which can manifest themselves at the junction of the pancreas and bile duct with the duodenum, are also a type that are not evaluated as different from pancreatic cancer until the surgical process.

Risk factors of pancreatic cancer

Although the causes of pancreatic cancer are not fully known, smoking and genetic factors are considered to be the most important risk factors for cancer formation.

The biggest known causes of pancreatic cancer can be listed as follows;

• 30% of pancreatic cancers are caused by smoking.

• Advanced age is an important risk factor for pancreatic cancer.

• Eating more protein and devoid of fruit and vegetables increases the risk of cancer.

• People with a high body mass index (BMI) are more likely to develop pancreatic cancer.

• Pancreatic cancer is more common in people exposed to oil and chemicals.

• Long-term untreated chronic pancreatitis increases the risk of developing pancreatic cancer.

• Diabetes doubles the incidence of pancreatic cancer compared to healthy individuals.

What are the symptoms of pancreatic cancer?

Pancreatic cancer can progress without symptoms in its early stages. When it starts to show symptoms, most of the time the disease has progressed.

Symptoms of pancreatic cancer may include nausea, loss of appetite, weight loss, slow-growing jaundice, gastric outlet obstruction and pain. In cancer that is located in the head of the pancreas, painless jaundice and stool are seen as light colored like glazier's paste. Pain in the back, which can be seen due to pancreatic cancer, is usually a harbinger of local spread of the disease, it is usually seen in the body and tail of the pancreas and is considered as a sign of progression of the disease. Less common symptoms of the disease are diabetes (diabetes), diarrhea (diarrhea), and depression, which we can remember as “3 D”.  

These symptoms can also be observed in pancreatic cancer:

• Abdominal pain that worsens after meals or when taking a horizontal position

• Gas pains, bloating

• Vomiting and loss of appetitedark or bloody urinegeneral malaise

• Enlargement of the liver and gallbladder

• Itching

• Arrival

  
  

  
  

In the case of such symptoms, it is important to consult a doctor as soon as possible.

Diagnosis in pancreatic cancer

Early diagnosis of pancreatic cancer may not be easy. Because there are no signs and symptoms in the early stages of pancreatic cancer. The fact that the symptoms of pancreatic cancer are similar to those of many diseases and that the pancreas is hidden behind organs such as the stomach, small intestine and liver is also effective in not making an early diagnosis.​

The diagnosis of pancreatic cancer is usually made by detailed imaging of the pancreas and its surroundings with the help of various tests. Determining the extent to which cancer cells have spread into and out of the pancreas (the spread of cancer) is called staging. Radiological imaging methods are used for staging. For an accurate treatment plan in pancreatic cancer, early diagnosis and cancer stage are very important.​

We can list the tests applied to diagnose pancreatic cancer as follows:

The patient's health history and physical examination:  The patient's general physical examination is performed and the diseases in his past are questioned. It is examined if there are diseases such as diabetes and pancreatitis, which are risk factors for pancreatic cancer.

Blood test:  A blood test is performed to measure the amount of certain substances such as bilirubin. Measurements that are higher or lower than normal are considered as a sign of disease in the organs or tissues that secrete that substance.

Tumor markers:  A tissue, urine or blood sample is taken and some measurements are made to detect the presence of cancer in the blood or tissue. During these measurements, two tumor markers, CA 19. 9 and CEA, can provide helpful information for pancreatic cancer. These tests are guiding in the follow-up of patients diagnosed with pancreatic cancer rather than making a diagnosis. These types of tests are not performed on healthy individuals.

Magnetic Resonance Imaging (MRI):  MRI is one of the important imaging methods for pancreatic cancer, as it is for all cancers. Especially your relationship with the tissues around the pancreas and inside the liver is very effective for understanding the findings.

Computed Tomography (CT):  It is one of the most guiding imaging methods in the diagnosis of cancer. In the CT application, which is also called computerized tomography or computerized axial tomography, the patient can be given intravenous or oral contrast material to improve the images.

Positron Emission Tomography (PET Scan):  PET scan is also used to detect the location and spread of the tumor. The patient is injected with a small amount of radionuclide-labeled glucose and the places where glucose accumulates are determined. As cancerous cells collect more glucose, they appear darker and are detected.

Abdominal ultrasound:  With abdominal ultrasound, high-energy sound waves are sent into the abdomen. These sound waves hit the tissues and echo. Thus, visualization of the inside of the abdomen and organs is provided.

Endoscopic Ultrasound (EUS):  It is a diagnostic method that is generally performed by inserting an endoscopy device with a light and imaging lens into the rectum or mouth. The echoes created by high-frequency sound waves are detected by the device, and a detailed image of the organs called sonogram is obtained, and if necessary, biopsy can be taken from suspicious areas.

Endoscopic Retrograde Cholangiopancreaticography (ERCP):  With this method, the pancreatic duct and the main bile duct and bile ducts can be visualized from the duodenum. A small tubular catheter is inserted through the endoscope into the pancreatic ducts and a detailed image of the bile ducts is taken by injecting contrast material.

Percutaneous Transhepatic Cholangiography (PTC):  A catheter is inserted and inserted through the skin with the help of ultrasonography to reach the biliary tract. Bile ducts are visualized using x-rays with the help of contrast material given through the catheter. If necessary, the catheter is left in place to drain the bile. This practice is referred to only in cases where ERCP cannot be performed.

Laparoscopy:  It is a surgical method that checks the symptoms of the disease by looking at the abdomen and internal organs from the inside. Tubular instruments, called ports, are inserted through the millimetric incisions made from the abdominal wall. With the camera and instruments entered through these ports, the abdomen is looked at. The location of the tumor and whether it has spread to the peritoneum or other organs can be visualized. A biopsy may be taken to make the diagnosis.

Biopsy:  It is the process of taking a cell or tissue sample for detailed investigation of cancer findings in the tissue. There are several different biopsy methods for pancreatic cancer. During x-ray or  ultrasound, a cell sample can be taken from the pancreas with a fine needle, or it is possible to perform the same procedure during laparoscopy.

Pancreatic Cancer Stages

Cancerous cells spread into the body through tissue, lymphatic system and blood. Cancer cells can break off from the main tumor and move to other parts of the body via blood vessels or lymph channels and form different tumors. This condition is called metastasis. Secondary or metastatic tumors have the same characteristics as the main tumor. It is difficult to detect pancreatic cancer stages using imaging tests. For this reason, it is very important to decide whether to remove the entire cancerous tumor before surgery.  

This is how we can explain the stages of pancreatic cancer:

Stage 0:  There is no propagation at this stage. And pancreatic cancer is limited to only one layer of cells. Pancreatic cancer is not visible on imaging tests nor with the naked eye.

Stage I:  In this stage, the cancer grows locally. Pancreatic cancer is confined to the pancreas.

Stage II:  Pancreatic cancer grows outside the pancreas or nears the lymph nodes.

Stage III:  At this stage, pancreatic cancer spreads more widely. The tumor has spread to nearby major vessels, lymph nodes, or nerves, but has not metastasized.

Stage IV:  In this stage, pancreatic cancer spreads to distant organs such as the liver.

Pancreatic Cancer Treatment

Pancreatic cancer treatment consists of 3 different methods: surgery, chemotherapy and radiotherapy. This brings up the intervention and control of different specialist physicians in the treatment of pancreatic cancer. Pancreatic cancer treatment is applied together with doctors who specialize in gastroenterology, surgery, medical oncology, radiation oncology, interventional radiology and many other fields.​

Most patients with pancreatic cancer are not candidates for therapeutic surgery because of early cancer spread to distant organs or extensive local involvement. These patients undergo surgical interventions that relieve obstructive symptoms such as jaundice and pain, do not prolong life, but aim to have a more comfortable period. Depending on the general condition of the patients and their co-morbidities, the average life expectancy in patients with pancreatic cancer spreading to other organs in the body is between 3 and 6 months. In patients with local spread of the disease, the average life expectancy is 6 to 10 months.

​The stage of the disease has a very important place in determining the treatment modality of pancreatic cancer.​

Resectable (suitable for surgical intervention, operable):  If the tumor can be removed in pancreatic cancer, surgical method, which is the only solution method, should be applied to cure pancreatic cancer. Even if the tumor is surgically removed, pancreatic cancer can often recur. Chemotherapy treatment with gemcitabine (gemzar) or 5-FU after pancreatic surgery can delay the recurrence of cancer for up to 6 months.  Regionally advanced:  Pancreatic cancer has progressed regionally but has not spread to distant organs. If the patient is not suitable for surgical intervention, interventions are made according to the patient's clinic. If there is a bile duct obstruction, a stent can be placed. If there is an intestinal area blocked by the cancer, a new path is opened between the stomach and the small intestine with the bypass.

Metastatic (widespread spread):  If pancreatic cancer has spread to the abdomen, liver, lungs, bones and brain, radiotherapy or surgical intervention alone will not be sufficient. One of the standard treatments for pancreatic cancer that has spread is chemotherapy treatment. This treatment is cancer shortens the patient's life expectancy.​

Recurrent (recurrent) Pancreatic Cancer:  Cancer that recurs in or near the same area after pancreatic cancer surgery is called recurrence. If the cancer is to recur in a distant region, it will first appear in the liver. When exocrine pancreatic cancer recurs, the same treatment is planned for metastatic cancer and chemotherapy is applied to the patient.​

Neuroendocrine Pancreatic Cancer (Pnet)

​Resectable (suitable for surgical intervention):  If surgery can be performed, the appropriate surgical technique is determined according to the type of tumor, its size and its location in the pancreas, and the operation is performed. Preoperative laparoscopy can be performed to determine the stage and exact location of the tumor. 

Unresectable (unsuitable for surgery):  Neuroendocrine pancreatic tumors usually grow slowly. In these tumors, the Gallium 68 DOTATOC method, which is one of the molecular imaging methods called endocrine cancer imaging, is used and the tumor can be examined. Two methods are used together in the treatment. In order to eliminate the problems caused by the hormone secreted from the tumor, the patient is given acid-reducing stomach drugs called proton pump inhibitors. Afterwards, chemotherapy, smart drug application and/or application of targeted radioisotopes are applied to regress the tumor.

Whipple surgery in pancreatic cancer 

Pancreatic cancer surgeries are the most difficult and complex operations of surgery. It is vital for the patient that both the surgeon and the hospital facilities are adequate, especially due to the risk of complications that may occur in the postoperative period. 

Whipple surgery in pancreatic cancer is a life-saving operation in tumors of the pancreatic head, biliary tract and 12 rectum. Whipple surgery is ideal for completely cleaning the area in tumors that occur in 3 organs that are close and connected to each other. During the Whipple surgery, the “Pyloric Protective Whipple” operation is applied to protect the muscular system, also called the gastric valve. Thus, there are no digestive system complaints after the surgery. With the Whipple operation, the head of the pancreas, almost half of the stomach, the entire 12 finger intestine and the adjacent part of the biliary tract are completely removed. The most important aspect of the operation is the correct coordination of these organs with each other. For this reason, Whipple surgery must be performed by specialist doctors.

Before pancreatic cancer surgery

Approximately 85 percent of patients diagnosed with pancreatic cancer are in the group that does not have a chance for surgery. In this case, some treatment options are used. These are applied as supportive treatment after surgery as well as shrinking the tumor before surgery and making it suitable for the surgical margin.    

Radiotherapy in pancreatic cancer

The most common type of radiotherapy used in the treatment of pancreatic cancer is external beam radiotherapy. It is usually applied at the same time as chemotherapy and radiation therapy will be more effective. Concurrent administration of chemotherapy and radiotherapy can help my pancreatic tumors shrink and disappear.

Chemotheraphy in pancreatic cancer

In order to stop the growth and division of pancreatic cancer cells, chemotherapy, that is, drug treatment, is performed.  

Targeted therapy in pancreatic cancer

Targeted therapy in pancreatic cancer; It is a treatment that targets certain genes, proteins, or tissue environment of cancer that contributes to the growth and survival of the cancer.

Nanoknife theraphy in pancreatic cancer

Nanoknife ablation therapy is an important option for patients who do not have a chance for surgery in pancreatic cancer. It is a process for the destruction of the tumor without leaving any damage to tissues such as vessels, nerves and intestines. In pancreatic cancer, which is one of the most important areas of use of the method, the most suitable patient group is those who do not have distant metastases but cannot undergo surgery because the surrounding vessels are involved. In this group of patients, called locally-advanced stage, the nanoknife can kill the surrounding tumor tissue without damaging the involved vessels and make the patients suitable for surgery again, or it can increase the survival time by shrinking the tumor. ​

Patients who are candidates for pancreatic cancer surgery, on the other hand, have points to consider before surgery. It is of great importance that the patient and doctor communication before the surgery, the operation being full-fledged and well-prepared for the operation, all the examinations according to the age and general condition of the patient and making a decision according to these examinations, the method of the operation and the pre-examinations meticulously carried out according to the condition of the tumor.    

What is the process after pancreatic cancer treatment?

Pancreatic cancer surgery is one of the major surgeries in general surgery. It is important to have an experienced surgical team for it to be effective. After these surgeries, some people may need to reduce their sugar consumption. After the operation, the patient should follow the doctor's recommendations. Treatment depends on the patient's condition and the stage of the disease. Chemotherapy and radiotherapy may also be required for treatment. At the end of the treatment, physicians will want to see the patient at certain intervals. These appointments should be adhered to. Doctors should be told in detail what kind of ailments are experienced. Various tests may be requested during the controls. Sometimes side effects can be seen after the treatment is finished. These must be shared with physicians. Sometimes weight loss may occur due to cancer. For this reason, physicians may want to take various nutritional supplements or new dietary habits. Some patients may experience pain. If pain occurs, the physician should be reported. In this regard, an effective and rapid pain management can be achieved. Good nutrition, regular physical activity, and maintaining a healthy weight are important after treatment. If necessary, patients may need emotional support.

What are the recovery signs in pancreatic cancer?

After Whipple surgery, which is a very important option in the treatment of pancreatic cancer, the patient can recover and return to his normal life within about 6 months. Surgery, which was not considered as an option for patients diagnosed with pancreatic cancer in the last 10 years, is an important alternative for patients with many different methods in today's conditions. Thanks to advanced imaging methods, the patient's chance of surgery is determined in advance and appropriate treatment is performed. Again, the extended recovery times due to open surgeries that cause large incisions in the body have been replaced by a faster return to normal life, where aesthetic concerns are eliminated, thanks to laparoscopic (closed) and robotic surgeries. Fast recovery after surgery It also allows patients to receive additional treatments that may be needed more quickly. In this way, signs of the presence of pancreatic cancer and the ten most common symptoms; Symptoms such as intense nausea, loss of appetite, involuntary weight loss, darkening of the urine color, obstruction at the gastric outlet, slowly developing jaundice, pain in the back, diarrhea, diabetes and depression also disappear after the treatment.  

FREQUENTLY ASKED QUESTIONS ABOUT PANCREATIC CANCER