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Pancreas Cancer

Pancreas Cancer



Where is the pancreas located?
 

The pancreas is a 15 cm long, slender and filigree gland, which is located crossways in the upper abdomen and whose form is similar to a walking stick with a thick handle. If one takes the spine as the middle of the body, then the thick handle (head of the pancreas) is located to the right of and in front of the spine. The body of the pancreas extends to the left (body and tail of the pancreas) across and past the spine. Fortunately, this tender organ is bedded like a thick sandwich in our upper abdomen: in the back, the bony spine is located, which is lined by the great blood vessels (aorta and vein) that run below the head of the pancreas. At the front side, the pancreas is covered by the stomach; to the right, the head of the pancreas is enclosed by the duodenum; and to the left, the tail of the pancreas is enclosed by the spleen. The tissue of the pancreas consists of many delicate small lobes, which again are made up of glandular cells. Their exits unite and discharge into the main duct, called the Ductus Wirsunganus, which runs horizontally through the pancreas and ends together with the great bile duct in the duodenum.
 
 
 

How does the pancreas function?

This highly complex organ can be well compared with a chemical factory, which produces in two different kinds of gland seven diverse substances (hormones and enzymes). The greater part of the tissue consists of glands, which produce an alkaline liquid (1.5 litres per day). It contains enzymes and flows through the Ductus Wirsunganus into the duodenum to crack the absorbed food into fats, proteins, and carbohydrates. Embedded and scattered in this tissue are the islets of Langerhans, which produce the vital insulin that regulates our glucose level. In case of a serious disease of the pancreas accompanied by a disturbed function of the gland, the patient may show the following symptoms:

  1. The missing gastric juice results in vitamin deficiency, loss of weight, and fatty stool as the absorbed food cannot be cracked any more.
  2. Less insulin is produced, the glucose level cannot be adequately regulated any more, and the patient gets into a situation of diabetic metabolism.




Carcinomas of the pancreas

The exact causes for pancreas carcinomas are still unknown to quite an extent. It can be surmised that there are genetic reasons for the development of such a carcinoma, but smoking as well as an alimentation rich in fat and protein are looked upon as being risk factors. The main importance is ascribed to the carcinoma of the glandular duct. It develops from its mucosal cells and accounts for 80% of pancreas carcinoma. The majority of these carcinomas are found in the head of the pancreas. Rarely, but very important for the course of the disease, malignant carcinomas are found, which originate from the islet cells or so-called neuroendocrine carcinomas, which consist of a mixture of hormone producing cells. Important to be mentioned are still those carcinomas, which proceed from the papilla, the confluence of the bile duct and the pancreatic duct into the duodenum. Hence, they originate so to speak in the "border area" of pancreas, bile ducts, and duodenum.
 
 
 

How can a malignant disease of the pancreas be recognised?

Unfortunately, the carcinoma of the pancreas causes few and very uncharacteristic complaints. The reason is that the pancreas lies deeply embedded between other organs, so that the carcinoma is not palpable and therefore - when finally diagnosed - has already far advanced in many cases. In the majority of cases, the patients observe unspecific complaints, which may occur in many diseases of gastroenteropathy: sensation of fullness, nausea and intolerance of food, fatigue, and loss of weight. Uncharacteristic pains in the upper abdomen, which may radiate as far as the back, are sometimes indications for the disease. If the carcinoma is located in the head of the pancreas, the common bile duct may be obstructed by the swelling, and the bile drainage may be disturbed. The gall contains gall pigments, which enter the blood if accumulated. This leads to itching of the skin, yellow skin, pale stool, and dark urine. Unfortunately, there are no clarifications, examinations, or radiological techniques that could definitely verify or rule out the carcinoma. Thus, the doctor has to distinguish the carcinoma of the pancreas from a chronic pancreatitis and other diseases of gastroenteropathy by an intensive questioning of the patient and further diagnostics. Questions about eating habits, consumption of alcohol, loss of weight, and pain in the upper abdomen belong to this questionnaire. The physical examination consists first of all of the palpitation of the upper abdomen to assess the gall bladder and the liver. Sometimes, a greatly enlarged but painless gall bladder is palpable, the Courvoisier's sign, which may be an indication of the carcinoma. In laboratory tests, the factors of the pancreas and the gall will be ascertained, and the tumour markers CEA and CA 19-9 are determined. In an advanced state of the disease, these markers are elevated, but unfortunately this is not only typical of this carcinoma. One will also certainly carry out an ultrasound of the upper abdomen. Thereby, one can see the distribution of space around the pancreas and assess enlarged and obstipated ducts of the gall and pancreas as well as changes in the liver tissue. After this, any further examinations will be carried out according to the individual case. A CT or MRI can detect pancreas carcinomas from a size of 1 cm upwards and show changes of the lymphatic glands as well as any growth extending into other organs. If there is the suspicion of a carcinoma close to the papilla (confluence of the ducts of the pancreas and the gall), endoscopic methods will be used (ERCP) to evaluate disturbances of the drain, to visualize ducts, and to take samples of the tissue (brush cytology).
 
 
 

How is a carcinoma of the pancreas treated?
 

If these diagnostic methods confirm a carcinoma of the pancreas without there being an indication of metastases, the tumour is surgically removed. If there is substantial suspicion of the existence of a carcinoma, the finding must be surgically counterchecked by taking samples of the tissue. In case of a positive result, surgery must be carried out. If metastases have been found during the diagnostic process, the tumour cannot be removed any more. However, depending on the circumstances, a new drainage for the stomach and the bile ducts into the small bowel has to be provided by surgery. In the case of a far advanced tumour, it can be tried to slow down its growth by applying chemotherapy. In the case of an operable tumour, the classical surgical treatment consists of a duodenopancreatectomy (according to Kausch/Whipple, see above). The head of the pancreas, the gastric outlet, the duodenum, the bile ducts, and the gall bladder are radically removed, and the drains into the smaller bowel are restored.

 
This operation was looked upon as being very dangerous and of little success for many years. The progress in the fields of surgery, modern methods of anaesthesia, intensive care, and intensive medicine have led to good results, however. Today, it seems, as if the state of health after this operation is satisfactory and superior to the non-operative methods. Indication and execution of this technically difficult operation belong into the hands of experienced and highly specialised surgeons and should be extensively discussed with the patient, the gastroenterologist, the oncologist, and the family doctor. Here is a short description of the surgical process: the access is laid by a crossways or vertical incision in the abdomen. The head of the pancreas and the near duodenum are exposed. At the lower side of the pancreas, the portal vein (the big supplying vein from the bowels to the liver) is found and is mobilized behind the neck of the pancreas. After this, the main hepatic duct is severed, the gall bladder and important lymph glands are removed, then also the neck of the

pancreas. In the further course of the operation, one part of the small bowel is joined to the neck of the pancreas. At a distance of about 15 cm, the hepatic duct is joined, and finally the gastric stump is connected to the small bowel.
 
At the end, drains are laid in the abdominal cavity. Another method is the Whipple procedure. Here, the body of the pancreatic gland and tail are removed, the head of the pancreas remains. During this operation, the spleen must often be removed as it lies very close to the tail of the pancreas on the left side. In the case of a carcinoma growing diffusely in the whole pancreas, a complete pancreas resection (Whipple operation) may become necessary. This operation has serious consequences for the patient due to the loss of the complete pancreatic tissue as he suffers a total loss of insulin and digestive enzymes that have to be immediately substituted. As non-surgical therapy, be it in the case of an inoperable tumour or as an additional therapy, chemotherapy and radiotherapy should be mentioned, which are applied in cooperation with the oncologist and the
radiologist.
 
 

 
 
 
What happens after the operation?

As after every great operation of the abdomen, the patients are treated at the intensive care unit for 2 - 3 days. The monitoring of respiration, circulation, and urine discharge as well as the administration of pain-killers and infusions are done round the clock. After the operation, antibiotics and a special medicine for the retardation of the digestive juice (somatostatin) are administered. After controlling of possible leakages and after a determination of amylase from the abdominal secretion of the drains, the latter are removed after 4 days and – with the stomach tube still in place - nutrition is started with great care if bowel sounds are already audible. At the same time, some blood readings are frequently controlled: lipase, amylase, and glucose value, which must perhaps be regulated by additionally administered insulin. Some patients may suffer from passing disturbances of gastric emptying. In the course of the following days, an assessment can be made how the functioning of the pancreas has been impaired and whether a replacement of digestive enzymes and the application of insulin will be permanently necessary.




What has to be paid attention to in future everyday life?

All patients, from whom tissue of the pancreas was removed, have to undergo permanent control of their pancreas readings and of the glucose value. If missing pancreas enzymes cause fatty stool and diarrhoea, they are substituted by adequate medicines. Along with this, the patient will receive nutritional guidance to be able to maintain a balanced diet with little fat and protein. If high glucose values occur, they are corrected by the administration of insulin. Family doctor, oncologist, and surgeon must stay in permanent contact, which is part of a routine follow-up care of the patient. During the last few years, new discoveries, improved early diagnosis, and new surgical techniques increased the survival rate of patients after a resection of pancreas considerably. In spite of this, the prognosis in such cases is still very serious because in many cases – even if the tumour was removed – small parts of it have to be left back in the body. This induced many doctors to be of the opinion that this operation is not successful enough, which is somewhat understandable. In spite of all this, we are of the opinion that an operation is indicated because, on the one hand, a definite diagnosis can only be made by means of a surgical treatment and, on the other hand, only during an operation it becomes clear whether a tumour can be removed or not. This is why intensive and worldwide attempts of research are directed towards improved methods of early diagnosis, but also towards new therapies to improve the prognosis for this tumour in the years to come.




History

Alexandria about 300 B.C.: In their hey-day, the Ptolemaic kings build a big university and library to let scientists, artists, and literary men do research work and teach. This is also where the physician and anatomist Herophilus of Chalcedon works because at this university, it is allowed to use corpses for anatomical studies, which is strictly forbidden in other countries. The first exact descriptions of the pancreas and the liver come from him. It was Johann Georg Wirsung, professor of anatomy at Padua, who in 1642 discovered the great excretory duct of the pancreas, which carries his name still today: Ductus Wirsungianus. Not knowing what he had actually found, he wrote to his teacher Jean Riolan: "But should I call it artery or vein? I did not find blood in it, however a turbid juice, which reacted on the silver searcher like an acid liquid…" The story had a bloody end: one year after his discovery, Wirsinganus was murdered in front of his door by a student. Had there been a dispute over who was the real discoverer of the duct? In 1869, it was the only 22 years old medical student Paul Langerhans who came across the islet cells of the pancreas while working on his doctor's thesis, but he did not know what function they had. About twenty years later, Oskar Minkowsaki and Joseph von Mering removed the pancreas from a dog to observe the consequences on the glycometabolism. The dog developed all symptoms of diabetes, and the two researchers furnished evidence of glucose and acetone in the urine. In this way, the connection between a malfunction of the pancreas followed by the development of diabetes had been proved. After Frederik Grant Banting and Charles Best had, around 1920, discovered the substance produced by the islet cells, namely insulin, it took only three years until the first insulin preparation appeared on the market. This meant salvation for the thousands of diabetics, for whom here had been no hope so far. The great surgeons of that time regarded the pancreas still as an organ hostile to surgeons because of its anatomical position and because of its fragile tissue. The operations were an extreme surgical challenge and the patient ran a high risk. But the surgeon Carl Gusenbauer, successor to Theodor Billroth at Vienna, was very innovative. Already as an assistant doctor, he had developed the first artificial larynx. He was not deterred by a delicate problem like that of the pancreatic pseudocyst, a complication of the chronic pancreatitis. He developed a technique which allows extracting the liquid from the cysts. In 1909, Walter Kausch opened new ways by carrying out the first radical pancreatectomy, which also entailed the removal of parts of the stomach and of the duodenum. Properly speaking, his technique established itself first as a therapy against tumours in the head of the pancreas. It was taken up by the famous Allen O. Whipple in the thirties, but it was later used quite often in the case of chronic and benign changes. The surgical aim to preserve as much of the organ as possible in the case of benign changes of the pancreas was achieved by Hans Georg Berger in 1971 through his new surgical method, maintaining the duodenum in the resection of the head of the pancreas. Its results bring along an inestimable advantage for the patient: a normal passage of the consumed food through the stomach and the bowels.