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Pancreatic Tumors

The pancreas is made of 2 components and has integrated functions, exocrine pancreas and endocrine pancreas (islets of Langerhans). The exocrine pancreas is responsible for the production of pancreatic juice and enzymes involved in digestion, while the endocrine pancreas is responsible for the production of specific hormone regulators of some key metabolic pathways in the body. The formal cancer that most frequently develops in the exocrine pancreas is pancreatic adenocarcinoma. So-called neuroendocrine tumours develop more frequently from the endocrine pancreas (see the dedicated section)

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Pancreatic cancer accounts for only 3% of all cancers but is the fifth leading cause of cancer-related death in the world. Its incidence has been increasing in recent years, probably due to improved diagnostic techniques (CT abdomen, abdominal MRI, endoscopic ultrasound with fine-needle aspiration).

 

Pancreatic cancer affects men and women equally, with a peak of incidence around the age of 60. In this country the Italian Cancer Registry indicates approximately 6,000 new cases per year with some differences between North and South; in the northern regions the incidence is higher, this discrepancy being probably due to different life styles and habits.

 

 

Symptoms of pancreatic cancer

The symptoms of pancreatic cancer are not easily recognised and related to the tumour; they often occur too late when the cancer has reached an advanced stage and therefore not able to undergo surgical resection. The most common symptoms include: jaundice (yellowing of the skin), weight loss, decreased appetite, digestive disorders, and abdominal pain often radiating to the back.

There is no specific screening for pancreatic cancer that may allow early diagnosis. The cause of pancreatic cancer is unknown. Some risk factors are cigarette smoking, diet rich in meat and low in fruit and vegetables, obesity, alcohol abuse, diabetes mellitus, and chronic pancreatitis. In very rare cases, there is a hereditary predisposition as a possible factor in the development of this disease (about 3%). The term familial pancreatic cancer (FPC) is used in the context of families with at least two first-degree relatives with pancreatic cancer.

 

Although the genetic defect responsible for the majority of cases of familial pancreatic cancer has not yet been recognised, the list of syndromes with specific genetic alterations at greater risk of developing pancreatic cancer is increasing. These syndromes include Familial Atypical Multiple Mole Melanoma (FAMMM), Peutz-Jeghers Syndrome (PJS), Hereditary Pancreatitis (HP), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), syndrome of Hereditary Breast and Ovarian Cancer (HBOC), Cystic Fibrosis (CF), Familial Adenomatous Polyposis (FAP), Ataxia-Telangiectasia (AT), and Fanconi’s Anaemia (FA).

 

At IEO, study and research programmes on this specific topic have been active for years.

 

 

Nutritional prevention 

Based on a careful evaluation of the results of scientific research, it has been possible to identify specific risk factors and protective nutritional factors for specific types of cancer. Experts have classified the results into four levels: "convincing evidence", "probable evidence", "limited evidence" and one last level that collects the effects for which evidence of association with the tumour is “highly unlikely." 

 

 

 

  • Risk factors for pancreatic cancers
    • overweight and obesity (convincing evidence
    • abdominal fat (probable evidence)

 

Protective factors for pancreatic cancers

Folate-rich foods such as green leafy vegetables (spinach, endive, escarole, chard), broccoli, wheat germ (probable evidence).

 

 

 

 

 



Surgery is still the cornerstone in the treatment of pancreatic cancer. Unfortunately, only 5% to 20% of all pancreatic cancers can be resected radically on diagnosis. The type of surgery depends on the affected location in the pancreas, the size of the tumour, and the need to obtain resection margins free of disease. Therefore, while in some cases the preservation of the pancreas is possible (duodenum-cephalo-pancreatectomy, distal splenic-pancreatectomy), in other cases the pancreatic gland must be completely removed (total pancreatectomy) with resulting pancreatic insufficiency, and diabetes mellitus.

 

For a possible resection surgery, it is fundamental to contact centres of reference, where perioperative morbidity and mortality are reduced to a minimum. This depends on one hand on expertise and experience of a high number of cases operated; and on the other, the expertise of different professionals working in harmony with one another (surgical oncologist, medical oncologist, radiologist, gastroenterologist, endoscopist, interventional radiologist, pathologist, nutritionist, endocrinologist). All these professionals have been at IEO since its foundation and they collaborate actively in the optimisation of diagnosis and treatment patterns of this form of cancer.

 

Advances in technology, techniques, and minimally-invasive surgical instruments have encouraged the application of the minimally-invasive laparoscopic approach to the treatment of pancreatic malignancies. Procedures such as laparoscopic staging and remote pancreatectomy have proven feasible and safe and appear to offer significant advantages compared to their corresponding surgeries performed by laparotomic access.

 

The effects on nutritional status and overall patient health due to the absence of the pancreas are effectively prevented through recommendations and personalised diet plans, provided by specialised personnel at the time of hospital discharge and during successive follow-ups. Possible metabolism alterations, including diabetes mellitus, are properly evaluated and promptly corrected with the support of endocrinologists. Both professionals are present at IEO and are an important resource for the overall management of the patient.

 

Adjuvant chemotherapy, aimed at preventing tumour recurrence, represents a reasonable approach in patients who are considered at high risk of relapse, although undergoing curative resection. In locally-advanced, unresectable or metastatic disease, chemotherapy alone is the treatment of reference. In recent years, systematic research has been made possible by optimising the treatment of advanced forms with improved survival and patients’ quality of life, mainly due to new combinations of the chemotherapy drugs. Gemcitabine, which for over a decade has been the only standard of care, and fluoropyrimidines have been joined by other drugs including oxaliplatin, irinotecan, and more recently nab-paclitaxel.

 

In case of jaundice, the placement of an internal biliary prosthesis by endoscopic route (by endoscopic retrograde cholangio-pancreatography, ERCP), is a viable alternative to palliative surgery with success rates up to 85%, low risk of mortality (1-2%) and significant reduction in the duration of hospitalisation.

In gastro-resected patients or patients that for other reasons cannot undergo internal prosthetic, external biliary drainage placement could be considered.

 

Clinical trials currently underway at IEO for this type of cancer are investigating dressing the application of new biological drugs in the treatment of metastatic disease and neoadjuvant chemotherapy in potentially resectable disease. Finally, one area of absolute novelty is represented by the search for molecular markers both in sporadic and family-hereditary forms.

 

 

Pancreatic cancer can even lead to nutritional consequences, such as malnutrition, cachexia syndrome (characterized by loss of fat and lean mass), significant body weight loss and reduced food intake due to anorexia.

 

 

Nutritional consequences of pancreatic resection surgery

Nutritional consequences of pancreatic resection surgery also derive from the type of operation performed. For example, in the case of distal pancreatectomy, better digestive function and absorption are seen compared to duodeno-pancreatectomy. Interventions can lead to maldigestion and malabsorption (due to lack of pancreatic enzymes), especially of lipids and fat-soluble vitamins, resulting in steatorrhea (presence of undigested fats in the stool) and reduced body weight. Reduced absorption of protein and total energy can be experienced. Another very common complication is insulin-dependent diabetes.

 

During surgery, a small probe is generally positioned (nutritional jejunostomy) to ensure physiological nutrition in the postoperative period (through the use of Enteral Nutrition - EN) as well as the required amount of nourishment when intake through the mouth is poor or inadequate as compared to the need. The nutritional jejunostomy is left in place at the time of discharge, and is used in cases where the patient is unable to take a proper diet to cover the nutritional requirements. After pancreatic resection, fat content in the diet should be controlled (no more than 30% of total caloric intake).

 

Depending on the surgery performed, taking capsules of pancreatic enzymes may be required. In specific cases the introduction of MCT to the diet may be appropriate (medium chain triglycerides). They are more easily digested and more quickly metabolised fats. The amount of simple sugars (honey, syrups, fruit juices) in the diet should be also controlled (kept below 10% of the total caloric content).

 

 

 

 


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