Source: Cancer Resource Room

What is Pancreatic Cancer?
Cancer of any part of the pancreas is called pancreatic cancer. Like all cancers, it is the result of abnormal cells growing and dividing without control. These abnormal cells form a lump (tumor) that grows bigger as the cells continue to multiply. The tumor crowds out the normal cells, takes up space, and presses on nearby tissues and organs. Cancer cells can break away from the tumor and travel through the blood or lymph vessels to other parts of the body. The cells can settle in another part of the body and start a new spot of cancer called a metastasis.

Pancreatic cancer is an uncommon disease. Each year, about 28,000 new pancreatic cancer patients are diagnosed in the United States. This may seem like a large number, but it is only about 2% of all new cancers each year. Cancer of the pancreas occurs mostly in older adults, usually over 60 years old. Younger adults can get pancreatic cancer, but it is less common.

What is the pancreas? What does the pancreas do?
The pancreas is a small, solid organ located behind the stomach and the first part of the small intestine. One end, the head of the pancreas, is near the liver. The other end, the tail of the pancreas, is near the spleen. The part in between is called the body of the pancreas.

The pancreas has two important jobs:

1. The pancreas makes digestive enzymes and fluids. These are released in the duodenum (the first part of the small intestine) to help digest food, especially fats. This is called the exocrine part of the pancreas.
2. The pancreas makes insulin and glucagon, the hormones that control sugar levels in the blood. This is the endocrine part of the pancreas.

Most cancers of the pancreas start in the digestive enzyme (exocrine) part. These are adenocarcinomas. Only about 5% to 10% are in the insulin-hormone (endocrine) part.

How is pancreatic cancer diagnosed?
Diseases are diagnosed by putting together several bits of information. Some information comes from the patient, like symptoms, or how the patient feels. And some comes from the patient’s medical history, what medical problems the person has had in the past. Information also comes from the doctor’s examination of the patient. And technical information comes from blood tests and xrays or other imaging studies. When all the pieces of information are collected, a suspected diagnosis can be made.

Sometimes the diagnosis needs to be proved by doing a biopsy. A biopsy means taking a small sample of tissue or cells to look at under a microscope. This is the only way to know the exact diagnosis of a disease.

Symptoms of pancreatic cancer- What does the patient feel or notice?
The symptoms are usually unclear. Symptoms often do not begin until the cancer has grown for some time and started to spread to nearby tissues. When symptoms occur, the include:

• Pain in the middle of the abdomen or back. The pain is usually constant, dull, and achy.
• Weight loss without dieting
• Poor appetite (not hungry)
• Tiredness
• Yellow color of the skin and eyes - called jaundice
• Change in bowel movements (feces are smelly, light-colored, and float).

Patient’s history – What the doctor should know about:

• History of tobacco use
• Diabetes
• Repeated pancreatitis
• Other family members with pancreatic cancer

Physical examination – What the doctor will look for
Examining the patient can find changes that might occur with pancreatic cancer. However, many physical changes from pancreatic cancer could come from other diseases and need to be confirmed by other tests. Physical changes can include:

• Jaundice—a yellow color of the skin and eyes
• Enlarged liver or gallbladder— organs can be felt along the edge of the ribs on the right side of the abdomen
  Tenderness in the right upper abdomen
• Swelling from fluid in the abdomen
• Enlarged lymph nodes, especially just above the left collarbone
• Part of the physical exam should include an evaluation of the person’s general health. This is called the person’s “performance status.” The surgery for pancreatic cancer is complicated, so the patient needs to be in good general health to have it done.

Blood tests:
No single blood test can find pancreatic cancer, but several tests are useful in suggesting problems in or around the pancreas. Some blood tests give information about the general health of the patient.

• CBC—blood count to check for anemia
• LFT’s—liver tests for enzymes and bile or bile products. These become abnormal when the liver is injured, diseased, or its bile ducts are blocked up.
• Amylase—an enzyme that increases if the pancreas is injured, inflamed, or diseased. If the amylase level is high, the pancreas is probably inflamed and does not have cancer.
• CEA—a protein in the blood called a tumor marker. It is not for any particular disease, but is often found in people with some form of cancer in the abdomen.
• CA 19-9—also a tumor marker, but is more likely to be found in patients with pancreatic cancer. The higher the level of CA 19-9, the larger the tumor or the more advanced the cancer.

Xrays and other imaging tests:

• Chest xray— This may show cancer spread to the lungs, fluid in the lungs, or an abnormal shape of the diaphragm (thin muscle separating the chest from the abdomen).
• Abdominal ultrasound— This test is painless and quick. Ultrasound pictures are made using a probe placed gently on the skin of the abdomen. The probe gives off sound waves into the abdomen. The sound waves are reflected back from the organs, vessels, and other tissues. The reflected sound waves form a black-and-white picture on a TV monitor. Ultrasound can make a picture of the pancreas showing its size, shape, thickness, and whether or not it contains abnormal tissue, including a tumor.
• CT scan—a series of xrays are taken in thin cross-sections across the abdomen. The xrays create pictures of the abdominal organs in layers. This is an excellent way to find a tumor, to see what size it is, and to see whether or not it has spread to nearby lymph nodes or other tissues. An abdominal CT scan shows the stomach, lymph nodes, liver, gallbladder and bile ducts, pancreas, small and large intestines, kidneys, major blood vessels, and part of the spine. The patient may need to drink a contrast solution to help show the digestive organs. An IV is used to give the patient contrast “dye” that travels through the blood. Contrast dye in the blood makes a person feel very warm for a brief time, and causes the feeling of needing to pee urgently. Both feelings pass quickly. CT scans are not painful but do require lying on a table for about 30 minutes.
• MRI—Magnetic Resonance Imaging is similar to CT scans, but it uses strong magnets rather than xrays to make the pictures of the organs. For pancreatic cancer, a good quality CT scan is usually able to show the problem clearly enough so an MRI is not necessary. If an MRI is done, the process is nearly the same as a CT scan.
• MRCP—Magnetic Resonance CholangioPancreatogram is a special MRI that takes thin cross-section pictures across the abdomen. It can show details of cancer in the gallbladder, liver, pancreas, bile ducts, large blood vessels, and lymph nodes. These images are used for diagnosis, finding spread of disease, and planning surgery. MRI and MRCP require that you lie on your back for about 45 minutes in a tunnel-like space. It is a closed space, and the equipment is noisy but painless. An IV is used to put some dye in the blood. The dye helps to show blood vessels and bile ducts.
• Laparoscopy—This procedure lets a surgeon look inside the abdomen with a laparoscope, a thin tube with a small camera on the end. The laparoscope is inserted through a small cut in the abdomen. It sends pictures from inside the abdomen to a TV monitor so the surgeon can see what tissues look normal and which do not. This helps plan the patient’s surgery and other treatments. Laparoscopy is done in the operating room with the patient under general anesthesia. Some hospitals use laparoscopy to decide whether or not the tumor has spread. Other hospitals use very high-quality CT scans to check for possible tumor spread.

These tests can be used in making a diagnosis of pancreatic cancer. They are also used for finding out how big a tumor is, whether or not it has spread to nearby tissues, and whether or not it has spread to the lymph nodes near the pancreas.

What is the stage of pancreatic cancer?
Stage means how far the cancer has spread inside the pancreas, to nearby tissues, or to lymph nodes and other organs. Stage describes:

• how large the tumor is
• whether the cancer has spread to tissues, blood vessels, and/or lymph nodes around the area of the pancreas
• cancer spread to lymph nodes and to other parts of the body such as the lungs, bones, or brain. This is called metastatic pancreatic cancer.

In general, the stages are as follows:

• Stage I—tumor can be larger than 2cm, but has not spread to lymph nodes or other tissues or organs.
• Stage II—tumor reaches to the duodenum, bile duct, or tissues around the pancreas, but not to the lymph nodes or other parts of the body.
• Stage III—tumor can be any size and can reach the duodenum, bile duct, or tissues near the pancreas. Tumor may have spread to nearby lymph nodes, but not to distant nodes or to other organs in the body.
• Stage IV A—tumor reaches to the stomach, spleen, colon, or nearby large blood vessels. Cancer has spread to lymph nodes, but not to other organs in the body.
• Stage IV B—tumor has spread to nearby tissues and organs, to lymph nodes, and has spread to other organs in the body.

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