Pancreatic Cancer

Clinical picture

The pancreas is an organ that forms part of the digestive system. Pancreatic cancer is an uncontrolled growth of malignant tumorous cells within the pancreas.

Since there are different cell types present within the pancreas, we distinguish two basic types of pancreatic cancer.

Exocrine cancers: these represent around 95% of all cases. These cancers originate in the cells that are responsible for producing enzymes that aid in the digestion of food.
Endocrine cancers: these only occur in up to 5% of all cases. They originate in hormone producing cells that are involved with blood sugar levels.

Adenocarcinoma is the most prevalent form of pancreatic cancer. It originates in the exocrine glands.

Less frequently occurring types of pancreatic cancer are:

Hamoudi tumour: usually a benign growth with a good outlook, also known as pseudopapillary tumour or Gruber-Frantz tumour. This type of tumour affects between 1 and 3 percent of all pancreatic cancer patients.
Neuro-endocrine tumour: a tumour type that can occur everywhere in the body, mostly in the digestive tract and the lungs. These tumours come with very diverse pathologies and symptoms.

In Belgium, around 1,500 patients per year are diagnosed with pancreatic cancer. Although a lot of resources are poured into research towards treatment, pancreatic cancer remains one of the least curable cancers. One of the main challenges with pancreatic cancer is the fact that the disease often does not get diagnosed until it is at a relatively advanced stage and has already metastasised.

Symptoms

Most patients with pancreatic cancer do not notice any symptoms during the early stages of the disease. The cancer only becomes apparent at a late stage, which means that treatment also starts relatively late, thus greatly reducing survivability.

The first things that patients notice are:

Pain in the back and abdomen. In the early stages of the disease the intensity of the pain may fluctuate but gets noticeably worse right after eating or when lying down.
Weight loss without plausible explanation.
Jaundice: yellowing of the skin and the whites of the eye. Urine may be darker than usual, whereas faeces may appear a lighter colour than usual.
Itching sensations all over the body.
Foul-smelling stools.

Further symptoms include:

nausea and vomiting
vomiting blood
changes in stool consistency (either diarrhoea or severe constipation)
Black, Tar-like stools
raised temperature
pain during eating and loss of appetite
bloating
blood clots
general fatigue and tiredness
an abdominal mass that can be felt

Cause

Despite many years of intensive research, scientists have yet to pinpoint the exact cause of pancreatic cancer. A few risk factors are:

chronic inflammation of the pancreas (pancreatitis)
smoking, excessive alcohol intake and diabetes type 2
pancreatic cysts
family history of pancreatic cancer or pancreatitis (in roughly 5 percent of all cases)
a history of melanoma or Von Hippel-Lindau’s disease (15 to 20% increased chance of contracting pancreatic cancer)

Diagnosis

When a doctor suspects a patient may have developed pancreatic cancer, he or she will be referred to an oncologist. The oncologist will then conduct investigations such as blood tests, echo tests and CT scans to confirm the diagnosis.

As soon as the diagnosis has been confirmed, further investigations are needed in order to establish how far the pancreatic cancer has advanced, what type it is and whether the disease has metastasised or not. This is done by MRI or MRCP scans, endo-echography and possible laparoscopy or an ERCP. Subsequently, a treatment strategy is decided upon.

An ERCP, endoscopic retrograde cholangio-pancreaticography, is an examination of the biliary and pancreatic tract. This is done by means of an endoscope, a flexible hose with a micro-camera attached to it. An ERCP can provide results that may not be obtained by traditional imaging technology. Usually, an ERCP investigation is only conducted by specialists when it is anticipated that a medical procedure has to take place during the examination.

Pinpointing the exact stage of the pancreatic cancer is invaluable when it comes to establishing a prognoses and deciding on a treatment plan.

Five stages

Stage 0: cancer cells are contained within the pancreas.
Stage 1: the cells have formed a tumour that is still contained within the pancreas. Two substages are:
- 1A: the tumour is up to 2 centimetres in diameter
- 1B: the tumour is larger than 2 centimetres in diameter
Stage 2: the tumour has grown outside the pancreas but has not yet reached the surrounding lymph nodes and/or blood vessels.
Stage 3: the tumour has grown outside the pancreas and has reached surrounding blood vessels, sometimes also metastasised into lymph nodes.
Stage 4: the tumour has metastasised to other organs and glands in the body. Usually these are the liver, abdominal cavity, lungs, lymph nodes and/or bones.

The differentiation of the tumour is an important factor in establishing a prognosis and treatment. This can be determined on the basis of a biopsy. A biopsy involves the removal of a small bit of tissue, which can be examined under a microscope. Differentiation determines the degree of mutation in the cancerous cells.

Treatment

Due to the fact that pancreatic cancer almost always gets diagnosed at a late stage, only 25% of all patients will receive curative treatment. But in most cases, treatment is limited to palliative care. In Belgium, patients with metastasised pancreatic cancer that has reached lymph nodes outside the operable area are not deemed suitable for operation. The same principle applies to patients where imaging has shown the tumour to be inoperable.

If examinations show that the tumour can be removed, then the patient is operated on and receives subsequent chemotherapy and/or radiotherapy to reduce the risk of recurrence or metastasis. The latter two treatments also form part of palliative care. Furthermore, if the patient’s cancer expresses a BRCA mutation, then PARP inhibitors can be used. Research into targeted therapy is currently ongoing.

Additional information

Currently, there are no dedicated patient groups for pancreatic cancer in Belgium. Flemish patients are referred to the Dutch organisation, whereas French speakers can find information with the French patient association AFRCP.