Pancreatic Cancer

Pancreatic cancer is a lethal disease, made more so by the fact that it usually does not cause any symptoms until it is advanced. Cancer arising in the body of the pancreas reveals itself in a more advanced stage, as it is hidden behind other organs. Cancer in the head of the pancreas usually compresses the bile duct and causes yellowing of the eyes and urine, called jaundice, usually accompanied by pale stools and itching.

Signs and symptoms of pancreatic cancer include:

• Jaundice (yellowing of skin, eyes and urine with pale stools)
• Abdominal pain
• Weight loss and loss of appetite
• Recent-onset diabetes

Anything that increases your risk of getting a disease is called a risk factor. The risk of pancreatic cancer increases with age. Some patients get this disease because they are genetically more prone, such as those with a family history or hereditary conditions like multiple endocrine neoplasia type 1 (MEN1), hereditary nonpolyposis colorectal cancer (HNPCC; Lynch syndrome), von Hippel-Lindau syndrome, Peutz-Jeghers syndrome, hereditary breast and ovarian cancer syndrome and familial atypical multiple mole melanoma (FAMMM) syndrome.

Risk factors for pancreatic cancer are:

• Old age
• Smoking
• Family history or hereditary conditions
• Chronic pancreatitis
• Obesity

Once pancreatic cancer is suspected, it is diagnosed and staged by a high-resolution, thin-cut, triple-phase CT scan. Your surgeon will also do tests to quantify your jaundice, check your kidney function, haemoglobin and blood clotting parameters. A tumour marker called CA 19-9 is also checked, along with a chest X-ray or CT scan of the chest to look for any tumour.

Based on the results, the disease is classified into resectable, borderline resectable, unresectable or metastatic.

• Resectable: the disease can be clearly removed by surgery.
• Borderline resectable: the cancer is infiltrating a vital vessel but can still be removed by surgery, either by cutting or re-joining the involved vessel and/or by giving chemotherapy or chemoradiotherapy before surgery (neoadjuvant treatment) to shrink the tumour.
• Unresectable: the disease has reached a stage where it cannot usually be removed surgically.
• Metastatic: the cancer has spread to organs beyond the pancreas; this is advanced stage and curative treatment is not possible.

The TNM staging system classifies the extent of the cancer:

• T (Tumour): How far has the cancer grown into the pancreas and nearby tissues?
• N (Node): Has the cancer spread to nearby lymph nodes? And to how many?
• M (Metastasis): Has the cancer spread to distant organs such as the liver or lungs?

The treatment depends upon the stage of the disease and the degree of jaundice. Surgery is the best possible option and can be considered if the cancer is diagnosed at a resectable or borderline resectable stage. If the jaundice is very high, the surgeon may decrease it before surgery by doing a procedure called ERCP and stenting, in which a plastic or metallic tube is placed in the compressed bile duct to open it up.

If the tumour is advanced, neoadjuvant treatment (chemotherapy or chemoradiotherapy) may be given to decrease the size of the tumour and increase the chances of survival. For unresectable tumours, an attempt is made to downstage them so that they can be surgically removed.

For metastatic cancers, surgery is not an option. After FNAC/biopsy and stenting (if jaundiced), chemotherapy is given to prolong survival. If the tumour blocks the passage of food, a metal stent is placed endoscopically, or a bypass surgery is done if this fails.

The surgery depends upon the location of the tumour. For cancers of the pancreatic head, a Whipple operation, also known as pancreaticoduodenectomy, is done. For cancer of the body and tail, distal pancreatectomy is done.

Whipple procedure (pancreaticoduodenectomy)

In pancreaticoduodenectomy, the head of the pancreas is removed along with the duodenum, bile duct, gall bladder, part of the stomach, a small part of the small intestine and adjacent lymph nodes. To restore continuity, the small intestine is then joined to the pancreas, the remaining bile duct and the stomach.

Distal pancreatectomy

For tumours of the body and tail of the pancreas, the tail along with the body (and often the spleen) is removed while the head is preserved.

In robotic surgery or laparoscopic surgery, we make a few small holes over the abdomen instead of a large cut.

Minimally invasive surgery markedly reduces post-operative stress and pain, leading to faster recovery and a shortened hospital/ICU stay. Blood loss is decreased, intestinal movement returns quicker and the overall complication rate is reduced — resulting in an earlier return to home and work.

Laparoscopic surgery for pancreatic cancer

Laparoscopic pancreatic surgery is performed through small keyhole incisions using a camera and long, thin instruments, allowing precise removal of the pancreas with smaller scars.

While pancreatic cancer cannot always be prevented, you can lower your risk by not smoking, maintaining a healthy weight, limiting alcohol and eating a balanced diet. If you have a family history or hereditary conditions, discuss screening options with your doctor.