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What is Pancreatic Cancer?

The Florida Hospital Cancer Institute offers the latest and most effective diagnosis, treatment and therapy for pancreatic cancer in Orlando for residents of Central Florida and the surrounding regions. The two major types of cancer that arise in the pancreas are cancers of the enzyme-producing glands and ducts called adenocarcinomas and cancers of the hormone producing cells called neuroendocrine tumors or neuroendocrine carcinomas.  Each type of tumor has a very different behavior, treatment, and outcome. To learn more about treatment for pancreatic cancer in Orlando, or to request an appointment, call (407) 303-1700 between 8 a.m. and 4 p.m. (Eastern Time) Monday through Friday. Or fill out our online assistance form and one of our coordinators will get back to you within one business day.

The pancreas is an organ located in the back of abdomen behind the stomach. It is divided anatomically into 4 parts: the head, the neck, the body, and the tail.  The head of the pancreas is located on the right side of the body just over the right kidney.  It is nestled in the curve of the first part of the small intestine called the duodenum.  The head of the pancreas is one of the most complex areas of the intestinal system.  The bile duct from the liver and the main duct of the pancreas join together in the head of the pancreas and empty into the duodenum through a common opening.  The head of the pancreas also wraps around the two main blood vessels that supply all of the intestines. The neck of the pancreas is a thin band of pancreatic tissue that runs over the main blood vessels of the intestines.  It is located over the middle of the body.  The body of the pancreas extends to the left of the body over the left kidney and adrenal gland.  It sits just behind the stomach.  The tail of the pancreas extends over the left kidney to the spleen, which is to the left of the stomach. 

The pancreas has two major functions.  First, it produces enzymes that aid in the absorption of foods, particularly fats. These enzymes are made in glands that make up the majority of the pancreas.  The enzymes are carried in a ductal system that extends from the tail to the head of the pancreas and are emptied into the first part of the small intestine to mix with food and aid in digestion.  Second, pancreas also produces hormones in small islands of cells called islets that are spread throughout the pancreas between the enzyme producing glands.  These hormones regulate numerous functions, mostly related to control of glucose (sugar) in the blood, intestinal function, and acid production in the stomach.  These hormones include insulin, glucagon, gastrin, vasoactive intestinal peptide, and somatostatin.  These hormones are released directly to the blood stream and do not use the ductal system of the pancreas. 

Adenocarcinoma of the Pancreas

Adenocarcinoma of the pancreas is one of the most aggressive and deadly of all human cancers.  It is the tenth most common cancer in both men and women, but it is the 4thmost common cause of cancer deaths in both sexes, accounting for about 37,000 deaths a year.  The risk of pancreatic adenocarcinoma increases markedly after age 50.  It is most commonly diagnosed between the ages of 65 and 80 and affects men slightly more than women.  The etiology of pancreatic adenocarcinoma is not well understood.  Known risk factors include a history of smoking, long standing diabetes, and chronic irritation of the pancreas known as chronic pancreatitis.  Only 5% - 10% of pancreatic adenocarcinomas result from a hereditary predisposition.  

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Symptoms of Pancreatic Cancer

Patients with adenocarcinoma of the pancreas commonly present with the following symptoms:

  • Unexplained weight loss
  • Pain
  • Malnutrition despite a good diet
  •  Jaundice
  • Anorexia
  • Itching
  • New onset of Diabetes in a non-obese adult over 40
  • Ascites
  • Intestinal obstruction

Unfortunately, by the time these symptoms occur, the disease has reached a more advanced stage.  Early pancreatic adenocarcinoma has relatively few symptoms that are significant enough for a patient to seek medical evaluation.  In addition, the disease is difficult to detect even in patients who receive regular medical care, and there are no reliable tests that can detect or screen for early pancreatic adenocarcinoma.

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Tests to Diagnose Pancreatic Cancer

If pancreatic cancer is suspected, there are multiple studies that can be performed to make the diagnosis and determine treatment options.  Diagnosis can only be confirmed with a tissue biopsy revealing pancreatic cancer.  The choice of studies to be used is individualized.  Studies are divided into two categories: Cross-sectional imaging and endoscopic imaging.

Cross-Sectional Imaging
This type of imaging includes high resolution CT scans and MRI scans.  This type of imaging will identify the presence of a mass and will assess for evidence of tumor spread and tumor involvement in critical structures such as major blood vessels in the area of the pancreas.  Quality imaging is crucial for treatment planning as it determines if the cancer can be removed with an operation.  The limitations of scanning are that it does not provide a diagnosis as there is no biopsy done, and some pancreatic cancers are too small to be seen by any cross-sectional imaging technique.  PET scans have little role in the diagnosis of pancreatic cancer.

Endoscopic Imaging
This type of imaging includes Endoscopic Retrograde CholangioPancreatography (ERCP) and Endoscopic UltraSound (EUS).  Both techniques are performed by highly specialized gastroenterologists.  ERCP examines the bile ducts and pancreatic duct by injecting contrast into these ducts through the opening in the duodenum called the ampulla.  If the bile duct is blocked by tumor, it can usually be opened during this procedure with a plastic or metal tube called a stent.  Tissue can also be removed to confirm the diagnosis of pancreatic cancer.  EUS involves using ultrasound built into an endoscope to look directly at the pancreas.  This technique is very sensitive for small masses, and can be used to precisely guide a biopsy needle into a mass to confirm a diagnosis of pancreatic cancer.  EUS can also examine the relationship of the cancer to nearby structures including blood vessels and lymph nodes, providing more information for a precise treatment plan. 

There are no laboratory studies that can diagnose pancreatic cancer.  However, there is a tumor marker called CA 19-9 that can be measured in the blood that can be useful in following treatment. 

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Pancreatic Cancer Staging

Pancreatic cancer staging is determined by the size of the main tumor, spread to lymph nodes, and spread to other organs.  Treatment choices and outcomes are determined by staging. 

  • Stage IA: The tumor is 2 cm or less in size and confined to the interior of the pancreas, no spread to lymph nodes
  • Stage IB: The tumor is greater than 2 cm in size but is still limited to the pancreas, no spread to lymph nodes.  
  • Stage IIA: The tumor extends outside the pancreas but does not involve major arteries in the area, no spread to lymph nodes.
  • Stage IIB:  Any size tumor, but the tumor has spread to local lymph nodes
  • Stage III:  The tumor involves the major arteries near the pancreas, +/- spread to lymph nodes
  • Stage IV:  The cancer has spread to distant sites.
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Treatment for Pancreatic Cancer

Treatment for pancreatic cancer is highly individualized and should be done in a multidisciplinary manner with experts in pancreatic surgery, medical oncology, and radiation oncology.  In this way, outcomes of treatment can be optimized for each patient with this disease.  Treatment can involve three components: Surgery, Chemotherapy, and Radiation.

Surgery

Surgery is the only therapy that can potentially cure pancreatic cancer.  The first step in treatment planning for pancreatic cancer is the determination of whether or not the patient is a candidate for surgical therapy.  In general, the major operations for pancreatic resection include pancreaticoduodenectomy for tumor in the head of the pancreas, and distal pancreatectomy with splenectomy for tumors in the body and tail of the pancreas.  These types of operations only benefit the patient if the tumor can be completely removed, leaving no tumor behind.  The operations are very complex and entail significant risks of complications.  Selection of appropriate patients for surgery is critical, and should be done by surgeons experienced in pancreatic surgery at institutions that perform a high volume of pancreatic surgery.

When being evaluated for surgery, patients fall into three general categories: resectable, borderline, and unresectable. 

  • Resectable:  The patients have tumors that do not involve major vascular structures and have no evidence of metastatic spread.  The patients are also in good medical condition and can tolerate a major operation.  These patients generally go directly to surgery
  • Borderline:  The patients have tumors that partially involve the major vessels around the pancreas but can still be removed leaving the vessels intact.  This category also includes patients with significant medical problems that have resectable tumors, but may not be able to tolerate a major operation.  In general, borderline patients receive some form of therapy including chemotherapy and/or radiation therapy prior to going to surgery. This allows time to shrink the tumors from the vessels as well as allows time for the patients' medical condition to be improved. 
  • Unresectable: The patients have tumors that completely involve major local vessels that cannot be removed, or the patients have spread of the cancer to other sites.  In general, these patients will not benefit from surgery and cannot be cured.  Chemotherapy and radiation therapy are used to prolong survival and help with symptoms.

Chemotherapy and Radiation Therapy

Chemotherapy and Radiation therapy for pancreatic cancer are used to improve survival after surgery, improve the chance that surgery can remove the cancer, and improve symptoms caused by the cancer.  Neither can cure pancreatic cancer without surgery.  They can be given before or after surgery and at any time for patients who cannot have surgery. 

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Prognosis

Pancreatic adenocarcinoma remains one of the deadliest cancers in humans.  Cure is unfortunately rare.  Survival data from the National Cancer Databank are below based on stage of the tumor. 

Survival - patients who CAN have surgery

Stage                                                 Percentage of  patients living 5 years after diagnosis

Stage IA                                                                       31%

Stage IB                                                                        27%

Stage IIA                                                                      16%

Stage IIB                                                                        8%

Stage III                                                                         7%

Stage IV                                                                         3%

 

Survival - patients who are unresectable

 

Stage                                                Percentage of patients living 5 years after diagnosis

Stage IA                                                                         4%

Stage IB                                                                         3%

Stage IIA                                                                        2%

Stage IIB                                                                        2%

Stage III                                                                         2%

Stage IV                                                                         1%

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Palliative Care

Patients who have unresectable disease at presentation or who have recurrence of their cancer after treatment are rarely cured.  Treatment options are limited at this point and are focused at prolonging survival with maximum quality of life.  Palliative chemotherapy and radiation therapy can slow progression of disease.  Pain management by pain specialists can minimize discomfort while maintaining good quality of life.  Advanced endoscopy, interventional radiology, and surgery can be used to deal with intestinal and bile duct blockage caused by tumor progression.  Hospice can be integrated into patient care in the later stages of the disease to ensure patient comfort, dignity, and quality of life.    

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Clinical Trials

All patients with pancreatic adenocarcinoma are encouraged to participate in clinical trials during the course of their disease.  As seen by the poor survival, medical science has had a difficult time finding effective treatments for this cancer.  There are many promising treatments on the horizon that will require clinical trials to prove their worth.  Participation is trials is key to improving treatment and outcome for this deadly disease. Click here to view current clinical trials.

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Request an Appointment

To learn more about treatment for pancreatic cancer in Orlando, or to request an appointment, call (407) 303-1700 between 8 a.m. and 4 p.m. (Eastern Time) Monday through Friday. Or fill out our online assistance form and one of our coordinators will get back to you within one business day.

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