Pancreas

In the U.S., pancreatic cancer is the 4th leading cause of cancer related death in both men and women. 1 Incidence rates have increased since 2000 and mortality rates have increased since 2001. African Americans have higher pancreatic cancer incidence and mortality rates than whites or any other racial/ethnic groups. Pancreatic cancer incidence and mortality rates are higher in men than in women. Diagnosis of pancreatic cancer before age 45 is rare. || Cause is unknown, but some environmental factors are implicated: 1 - Smoking - diets high in meat or fat - prior history of surgery for peptic ulcer - long term diabetes - inflammation of pancreas - certain hereditary conditions || Jaudice, which may be present in up to 50% of patients affected by this disease, is one of the most common signs. In addition, weight loss and abdominal pain are common signs. Other signs and symptoms of pancreatic cancer are non-specific and require close attention by physicians to ensure that appropriate diagnostic tests are done. These secondary signs include: 2 The most common primary malignancy is adenocarcinomas, cancer of the epithelium in glandular tissue. Infiltrating ductal adenocarcinoma, originating from the exocrine (digestive enzyme-producing) part of pancreas, account for about 90% of pancreatic tumors. Some other histological types include acinar cell carcinomas, and cystadenocarcinomas. 4 || Primary lymphatic drainage is to superior and inferior pancreaticoduodenal,porta hepatis, celiac, and superior mesenteric nodes. 5 || The cells are graded according to how like or unlike normal cells they are when looked at under a microscope. 7 There are 4 groups (called grades 1 to 4), according to the size and appearance of the nucleus of the cancer cells. Grade 1 cancer cells are the most similar to normal cells. Grade 4 cells are most unlike normal cells. The higher the grade, the more quickly the cancer is likely to grow. || The following is the TNM staging for Pancreatic cancer: 8 The most common side effects of treating pancreatic cancer with radiation is nausea and vomiting. 9 This is mainly due to where the pancreas is located in the abdomen. These side effects are usually resolved with antiemtics (antinausea). 9 Some other side effects include: leukopenia, thrombocytopenia, diarrhea, and stomatis. 9 A chronic side effect may be renal failure. 9 However, this may be due to improper shielding throughout the course of treatment of one or both kidneys. || The prognosis of pancreatic cancer is heavily dependent on tumor size and the progression of the disease. Generally speaking, only 20% of patients diagnosed with the disease survive 1 year. 10 In addition, the 5 year survival rate is a disheartening 4%. 10 These survival rates directly reflect the poor likelihood of early diagnosis. Approximately less than 20% of patients have tumors confined to the pancreas and are eligible for surgery. 10 In patients where surgery is an option, the typical survival range is 18-20 months. 10 Tumor size is a significant indicator in complete resection of the cancer. The larger the tumor, the more difficult the resection becomes with negative margins. 10 If all of the disease is not surgically removed, the patients have a poorer prognosis. Finally, the progression of pancreatic cancer is the biggest indicator of a quality of life prognosis. The disease is often accompanied by weakness, weight loss and pain making it very difficult for patients to live with the disease. 10 || There are 3 main types of treatments for patients diagnosed with pancreatic cancer. These options include surgery, chemotherapy, radiation therapy, or a combination of any or all of these modalities. > || Tissue dose associated with 5% injury rate within 5 years 13
 * **Epidemiolgy:** || Lindsey
 * **Etiology:** || Lindsey
 * **Signs & Symptoms** || Kevin T.
 * Anorexia
 * Pruritis
 * Alterations in bowel habits
 * Thrombophlebitis
 * Depression
 * Glucose intolerance ||
 * **Diagnostic Procedures:** || Kevin T.
 * Computed tomography (CT) is the initial test done for evaluation of symptoms suggestive of pancreatic cancer.
 * T1- and T2- weighted magnetic resonance imaging (MRI) may be useful.
 * Endoscopy, or endoscopic retrograde cholangiopancreatography (ERCP) is used for visualizing the common and pancreatic ducts in order obtain tissue biopsy or cytologic samples. In addition, the test may indicate obstruction of the common bile duct, as well as a stricture in the pancreatic duct.
 * Endoscopic ultrasonography (EUS) can guide the use of fine-needle biopsy. It has an accuracy of 75-92% in identifying pancreatic neoplasms.
 * Percutaneous needle biopsy, using either CT or ultrasonographic guidance demonstrates high sensitivity and specificity in the diagnosis.
 * Liver function tests have the ability to possibly identify an obstructive component.
 * Tumor marker CA-19-9
 * Laparoscopy to identify peritoneal implants or metastases on the liver surface. 3 ||
 * **Histology:** || Jenn
 * **Lymph node drainage:** || Jenn
 * **Metastatic spread:** || Rachel
 * A major concern when diagnosing pancreatic cancer is whether or not the cancer has already spread outside the pancreas. The location of the metastases will determine if the cancer can be surgically removed. 6
 * Lymph nodes: lymph nodes in the groove between the duodenum and the pancreas are a very common site of metastases. These are considered locoregional and can usually be removed during whipple surgery. The spread to more distant lymph nodes, such as those closer to the liver, may mean that the tumor is unresectable.
 * Liver: This is a common find, especially with tumors in the tail and body of the pancreas. Usually in this case, surgery will not be an option.
 * Celiac plexus: It is these nerves that cause back pain when pressed upon by a growing tumor.
 * Superior mesenteric vessels: This artery and vein carry blood to and from the bowels and are closely associated with the pancreas. They may become involved by the spreading of the tumor.
 * Ligament of Treitz: This is a thin muscle that wraps around the small intestine where the duodenum and jejunum meet. It passes behind the pancreas.
 * Portal Vein: This is another important blood vessel that runs right next to the pancreas. It carries oxygen poor blood to the liver where it is filtered. It's possible that in this case the tumor may be considered unresectable in most cases. ||
 * **Grading:** || Rachel
 * **Staging:** || Brandon
 * Primary tumor (T) **
 * TX: Primary tumor cannot be assessed
 * T0: No evidence of primary tumor
 * Tis: Carcinoma //in situ//
 * T1: Tumor limited to the pancreas, ≤ 2 centimeters (cm) in greatest dimension
 * T2: Tumor limited to the pancreas, > 2 cm in greatest dimension
 * T3: Tumor extends directly into any of the following: duodenum, bile duct, prepancreatic tissue
 * T4: Tumor extends directly into any of the following: stomach, spleen, colon, adjacent large vessels
 * Regional lymph nodes (N) **
 * NX: Regional lymph nodes cannot be assessed
 * N0: No regional lymph node metastasis
 * N1: Regional lymph node metastasis
 * N1a: Metastasis in single regional lymph node
 * N1b: Metastasis in multiple regional lymph nodes
 * Distant Metastasis (M) **
 * MX: Present of distant metastasis cannot be assessed
 * M0: No distant metastasis
 * M1: Distant metastasis ||
 * **Radiation side effects:** || Brandon
 * **Prognosis:** || Ashley
 * **Treatments:** || Ashley
 * Surgery: Patients that are favorable for surgery may undergo a pancreatoduodenectomy (whipple procedure), total pancreatectomy, or distal pancreatectomy. The whipple procedure is a procedure in which the head of the pancrease, gallbladder, bile duct and part of the stomach and small intestine are all removed. 10 The remaining parts of the pancreas are still able to digest juices and insulin. This procedure is very difficult and few patients qualify for it. The most successful surgeries are performed at cancer centers where over 20 pancreatoduodenectomy procedures are done every year. A total pancreatectomy removes the whole pancrease, common bile duct, gall bladder, spleen, proximal lymph nodes and parts of the stomach and small intestine. 10 A distal pancreatectomy removes the spleen and body and tail of the pancreas. 10 Each of these 3 methods are performed with the hopes for complete resection.
 * Chemotherapy: Chemotherapy agents are used to prevent the growth and further spread of cancer cells. The drugs can be administered a variety of ways and include Fluorouracil, Elotinib Hydrochloride, Gemcitabine Hydrochloride, Gemzar, Mitomycin C, Mitomycin C and Tarceva. 10
 * Radiation Therapy: In the treatment of pancreatic cancer, external beam radiotherapy can be used. Anterior/Posterior, Posterior/Anterior and opposed lateral fields can be used to treat the lesions. 11 Typically, 40-50Gy is used to treat these lesions. 11 More recently, Intensity Modulated Radiation Therapy (IMRT) has improved conformity around the pancreas and limits dose to the spinal cord, liver, kidneys, stomach and small bowel. The image below is a typical IMRT plan for a pancreatic lesion.
 * **TD 5/5:** || Amanuel
 * Liver: 3000cGy [Acute and chronic hepatitis]
 * Kidney: 2300cGy [Nephritis]
 * Stomach: 5500cGy [Ulceration/perforation]
 * Small bowel: 4500cGy [Obstruction/perforation]
 * Spinal cord: 4700cGy [Myelitis/necrosis] ||
 * **References:** || Amanuel
 * 1) National Cancer Institute Web
 * 2) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2011: 376-386.
 * 3) Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby; 2010. 793-797.
 * 4) Oxford Journals. Pancreatic cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Available at: [] . Accessed June 13, 2013.
 * 5) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd . Philadelphia, PA: Lippincott, Williams & Wilkins; 2011: 427-428.
 * 6) Metastasis. Johns Hopkins Medicine Web site. []. Accessed June 13, 2013.
 * 7) Statistics and Outlook for Pancreatic Cancer. Cancer Research UK Website. []. Accessed June 13, 2013.
 * 8) Chao K, Perez C, Brady L. //Radiation Oncology Management Decisions //. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002: 348.
 * 9) Washington C, Leaver D. //Principles and Practice of Radiation Oncology. // 3rd ed. St. Louis, MO: Mosby Elsevier; 2010:891-892
 * 10) Prognosis of Pancreatic Cancer. Hirshberg Foundation for Pancreatic Cancer Research Web site. [] . Accessed June 12, 2013.
 * 11) Pancreatic Cancer Treatment. National Cancer Institute Web site. [] <span style="background-color: #ffffff; color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">. Updated January 23. 2013. Accessed June 12, 2013.
 * 12) <span style="color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">Cancer Center News. Massachusetts General Hospital. <span style="color: windowtext; font-family: Arial,sans-serif; line-height: 1.5;">[] <span style="color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">. Accessed June 13, 2013
 * 13) <span style="background-color: #ffffff; color: #ff7100; font-family: Arial,sans-serif; line-height: 1.5;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010 ||

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