Pancreatic Cancer

What is the pancreas?
Tell me about cancer of the head of the pancreas.
What symptoms do patients have for this kind of cancer?
How does the doctor know I have this?
How is this treated? Will I need surgery?
Will the surgery cure me? What will my life be like after the surgery?
Tell me about cancer of other parts of the pancreas.

What is the pancreas?
The pancreas is a long flat organ found over the spine behind the other abdominal organs. Its function is to produce enzymes to digest food, and insulin to control the body’s use of sugar. The head of the pancreas is on the right and the tail is on the left. Symptoms of pancreatic cancer will depend on where the cancer is located. Cancer of the head of the pancreas causes jaundice and cancer of the tail of the pancreas produces pain.

Tell me about cancer of the head of the pancreas.
There are four cancers that can occur near the ampulla of the duodenum, which is just past the stomach. The ampulla is a small muscle that surrounds the end of the bile and pancreatic ducts. Cancers can form in the ampulla itself, in the duodenum, in the bile duct, or in the head of the pancreas. These cancers are referred to as “periampullary” cancers because of their location. They are all listed together because the symptoms, diagnostic testing, and treatments of these cancers are similar.

Pancreatic head cancer is the most frequent cancer of the periampullary area and is the 4th leading cause of cancer deaths in man in the U.S. Almost 30,000 people die from pancreatic cancer yearly. About 80% of the patients with periampullary cancer are over 60 years of age. The most frequent type of malignancy of this area is called adenocarcinoma. There are other, more rare, types of malignancy, such as that from the endocrine cells of the pancreas, or from cystic tumors, such as mucinous cyst adenocarcinoma. There are also even more rare types of malignancy such as sarcomas and lymphomas. Metastasis (spread of cancer to the pancreas from another area of cancer in the body) to the periampullary area also frequently occurs from other organs such as lung, stomach, breast etc.

What symptoms do patients have for this kind of cancer?
Smoking doubles the risk of this cancer. Thirty percent of patients who develop pancreatic cancer develop diabetes the year prior to diagnosis. Patients with cancer of the periampullary area usually have jaundice. Their urine becomes dark and friends inform them that the skin and eyes look yellow. Pain is not a major symptom, but they may have abdominal discomfort and loss of appetite. Cancers of the duodenum or the ampulla may cause vomiting, bleeding, anemia, and black or silvery stools. On examination there are rarely any physical findings except for jaundice and a large gallbladder felt underneath the right rib cage as it becomes distended due to obstruction.

How does the doctor know I have this?
Your surgeon will be interested in detailed studies to tell him as much as possible about your disease so that he can recommend the best treatment for you. You may be told that you need any of the following tests. Blood chemistries will demonstrate that the bilirubin and alkaline phosphatase are elevated. A CT scan is ordinarily performed, which will demonstrate a mass in the pancreas with large pancreatic and common ducts. CA 19-9 is a tumor marker, which is produced by pancreatic cancer and may often be elevated. This can be used as a tool to determine the activity of the tumor and the response to therapy. This test is also useful after curative surgery, as the CA 19-9 will go down to normal and will become elevated if the tumor recurs. Many, many other tests can be offered to the patient who has periampullary cancer. If a cancer of the ampulla or duodenum is suspected, gastroscopy will demonstrate the tumor. An ERCP is performed almost routinely, but it is not indicated most of the time unless there is a question of pancreatitis. Similarly, routine use of needle biopsy of the pancreas is not advisable. It should be used to prove metastasis, in which case surgery is not curative and therefore not indicated.

How is this treated? Will I need surgery?
You will need surgery for cancer of the head of the pancreas if the tumor has not spread. The surgical treatment for cancer of the head of the pancreas and the other periampullary cancers is a Whipple operation. In this operation the bile duct is transected (cut), and the pancreas is transected at the junction of the body and tail. The stomach is transected from the duodenum (called pyloric saving) or part of the stomach is removed and the small bowel is transected just past the duodenum. Then the small intestine is connected to all the transected organs. This is a very complicated operation, which should be performed by someone who performs many of these. The complications of the surgery are many and can range from bleeding to infection, to obstruction, pneumonia or blood clots. This is why it is important that the surgeon you choose has done many of these procedures, and you should always ask this question of your surgeon.

At times you may need surgery even though cure is not probable to help you with problems of vomiting or jaundice which cannot be relieved with a non-operative means.

Will the surgery cure me? What will my life be like after the surgery?
In the hands of an experienced surgeon the death rate from the surgery is less than 2 - 5% with a five-year survival rate (or cure) of 20%. Statistics are very difficult to interpret because various surgeons report their findings using different methods. The cure rate for the other periampullary cancers is much better and approaches 50-60%

The quality of life after surgery is very acceptable. A few patients who were pre-diabetic may need small amounts of insulin and occasionally others may require pancreatic enzymes.

Follow up after surgery is important and a medical oncologist is often consulted for chemotherapy. If it is demonstrated that the patient has disease that has metastasized (spread to other parts of the body), then chemotherapy and radiation are both used. Jaundice is alleviated with a stent, which is an artificial bridge that is placed through the liver and the bile duct into the duodenum. This takes care of the jaundice without surgery.

Tell me about cancer of other parts of the pancreas.
Cancer of the body and tail of the pancreas, in comparison to periampullary cancer, presents most often with pain, weight loss and loss of appetite. These cancers are usually not cured with surgery. If the CT scan demonstrates that the lesion is resectable (can be taken out with hope for cure), the surgeon will resect (cut out) the body and tail of the pancreas and also remove the spleen. This surgery is somewhat less difficult than the Whipple operation, but more patients become diabetic. Because the spleen is removed, the patient will need protection against certain bacteria. They receive vaccines against pneumococcus, meningococcus and hemophilus. The medical oncologist plays a very crucial role in the care of these patients.

University Surgeons is nationally recognized for its excellence in the diagnosis, treatment, and surgery of cancer of the pancreas. The doctors listed below meet the criteria of having done many operations for cancer of the pancreas:
John L. Butsch, M.D.
Daniel J. Deziel, M.D.
Alexander Doolas, M.D.
Keith W. Millikan, M.D.