Pancreatic cancer (pancreatic carcinoma)

Cancer of the pancreas in the vast majority of cases (95 percent) so-called carcinomas, ie malignant tumors. They grow in the tissue of the pancreas, which forms the digestive enzymes. In technical language, they are referred to as pancreatic carcinomas.

Pancreatic cancer is usually discovered late and spreads relatively quickly (metastasis). This makes pancreatic carcinoma one of the most insidious tumors.

Like all malignant tumors, pancreatic cancer is characterized by an uncontrolled proliferation of tumor cells. They have a tendency to grow into adjacent healthy tissue and destroy it. Individual tumor cells can be carried away with the blood or lymph stream and form secondary tumors (metastases) in distant organs, for example in the lung, liver or skeleton.

Pancreatic carcinoma is very difficult to cure

Pancreatic cancer is a rather rare type of tumor. In Germany, around 16,000 people suffer from it each year, and men and women are equally affected. In its course, however, the pancreatic carcinoma is very treacherous: Malignant neoplasms of the pancreas are often discovered only at an advanced stage, in which the tumor is curable only in the rarest of cases .
Life expectancy is low in such cases: The five-year survival rate for diagnosed pancreatic cancer is just eight percent. Thus, the pancreatic carcinoma has the lowest survival rate of all cancers .

Facts and figures about pancreatic cancer
In most cases, pancreatic cancer is diagnosed at an advanced age, the mean age of onset is 69 years in men and 76 in women. However, the tumor also occurs in people under the age of 50 years.
A pancreatic carcinoma develops mainly (60 percent) in the so-called head part of the pancreas (pancreatic head carcinoma) or in the area where the duct of the gland flows into the duodenum (papillary carcinoma). In 30 percent of cases, the tumor develops in the region of the pancreas or tail. In ten percent of cases, the entire gland is affected.

Pancreatic cancer: causes and risk factors
The actual cause of pancreatic cancer is previously unknown. One knows only risk factors, which can favor the emergence of the illness. Smoking, lifestyle and genetic predisposition can play a role in the development of pancreatic cancer.

Smoking and environmental toxins increase risk
The most important known risk factor for the development of pancreatic cancer is smoking. Various studies suggest that about 30 percent of the cases are due to cigarette smoking . The risk of getting pancreatic cancer is about four times greater in smokers who smoke a pack of cigarettes daily than non-smokers. There is a link between the duration of smoking and the number of cigarettes smoked and the number of new cases of pancreatic cancer.

Other pollutants from the environment increase the risk of disease. These include, for example, polychlorinated biphenyls (PCBs), which are used by industry as plasticizers for paints and adhesives . Also pesticides such as the now banned in Germany DDT and compounds of benzene , a key raw material in the chemical industry seem to promote the disease.

Cholesterol and alcohol damage the pancreas

Besides smoking and environmental pollutants , nutrition also plays a role in the development of pancreatic cancer For example, high levels of dietary cholesterol and carbohydrates appear to increase the risk of the disease. The role of excessive consumption of coffee and / or alcohol in the development of pancreatic cancer is not clear, and there are contradictory findings.

Rarely do the genes play a role
In rare cases (around three percent), pancreatic cancer is associated with hereditary diseases. This includes Ataxia teleangiectatica , a disease that is associated with, among other things, movement disorders immune deficiency and an accumulation of malignant diseases.

These symptoms may indicate pancreatic cancer
Pancreatic cancer causes signs of disease only at an advanced stage. Typical are belt-shaped pain, weakness and weight loss . Tumors in the head of the pancreas can cause jaundice (jaundice).
Pancreatic cancer causes late onset of disease . Therefore, in 90 percent of affected patients, the disease is already at an advanced stage when it is detected. The tumor has then usually breached the boundaries of the pancreas and has grown into the surrounding tissue. Thus, the duodenum , stomach , bile duct , spleen , large intestine or large blood vessels in the area may already be affected before complaints occur.

Pain in the upper and middle abdominal area
In addition to weight loss and general weakness occur as a typical symptoms belt-like pain in the upper and middle abdominal area, which can radiate into the back. Tumors in the region of the pancreas head can close the bile duct, which opens into the small intestine in this area together with the pancreatic duct.

Bile can no longer run off
The bile, which is formed in the liver , then can no longer flow into the small intestine . As a result, bile components accumulate in the blood, including the breakdown product of the red blood pigment called bilirubin . As a result, the skin and the white area of ​​the eye turn yellowish. This discoloration is called jaundice . The patient also notices a discoloration of the stool and a darkening of the urine. Often the patients also feel a tormenting itching .
Jaundice may be the first and only sign of pancreatic cancer. Therefore, this disease sign must be promptly investigated to clarify the cause.

Pancreatic carcinoma and metastases
It is characteristic of pancreatic cancer that the tumor forms early metastases , for example in the lymph nodes of the abdomen, in the liver or in the lungs . Also hereby first signs of disease can be caused, for example, a ascites (ascites). By this one understands a fluid accumulation in the free abdominal cavity , which can be caused by an infestation of the liver with daughter tumors. The metastases hinder the blood flow through the liver, and the blood congestion is increasingly pressed liquid from the blood vessels in the abdomen . Even with an infection of the peritoneum With daughter tumors (peritoneal carcinomatosis), there is often an ascites, as the affected peritoneum increases fluid and releases into the free abdominal cavity.

Tendency to thrombosis in pancreatic cancer
Patients with pancreatic cancer often have inflammation and blood clots in the veins (thrombophlebitis, thrombosis), for example in the deep veins of the leg. The constriction of blood vessels in the abdomen and tumor-related activation of the coagulation system favors the formation of blood clots and thromboses. Therefore, if such diseases occur repeatedly for no apparent cause, a pancreatic examination should also be considered.

Investigations and tests in case of suspected pancreatic cancer
If pancreatic cancer is suspected, various methods of examination are used in stages until the disease is reliably diagnosed.
If there is a suspicion of pancreatic cancer due to the signs of the disease , various investigations will be carried out for clarification. This makes it possible to diagnose more than 90 percent of patients with pancreatic cancer.

Physical examination in case of suspected pancreatic carcinoma
The following findings may be groundbreaking during the physical examination :
  • Jaundice When the pancreatic tumor obstructs the flow of bile into the small intestine, the bile accumulates in bile ducts and gallbladder. A congested gallbladder can be palpated during physical examination in up to one-third of pancreatic cancer patients. An outflow disorder of bile leads to jaundice (jaundice). The patient notices a discoloration of the stool , a darkening of the urine and a yellowing of the skin and conjunctiva of the eyes . At baseline, half of patients with pancreatic cancer have jaundice.
  • Liver and spleen enlargement Tumors in the area of ​​the pancreatic tail, which extends to the spleen , may obstruct the flow of blood from the spleen. This leads to an enlargement of the spleen, which can be palpated during the examination in the region of the left upper abdomen. The liver can be hardened by daughter tumors and clearly palpably enlarged.
  • Conspicuous palpation of the abdomen At the time of the initial examination, 90% of the patients had already spread to the pancreas or to the local lymph nodes . During abdominal examination , these large tumors can be directly palpable through the abdominal wall.
  • Lymph node swelling If tumor cells spread through the lymphatic system and settle in the lymph nodes, this can lead to palpable lymph node enlargements. In pancreatic cancer , the lymph nodes above the left collarbone may also be enlarged.
  • Ascites ( ascites ) in up to a quarter of patients with pancreatic cancer is already at baseline is a collection of free fluid in the abdomen (ascites, ascites). It is an expression of a very advanced disease in which the tumor has infested the liver or peritoneum .

Laboratory tests for diagnosis
There are no laboratory findings that can safely detect or rule out pancreatic cancer. In addition to the usual measurements of blood values , such as blood cell lowering rate ( ESR ), blood count and liver function values , the blood is examined for so-called tumor markers . These are special substances that are formed by some tumors and released into the blood.
The tumor markers in the blood are determined to detect a possible relapse in certain diseases, the course, the response to the therapy and after successful treatment. In no case can they be used to detect or rule out tumor because there are always tumors without markers. They are therefore unsuitable for carrying out a general tumor search.

Treatment options for pancreatic cancer
Since the treatment of pancreatic carcinoma depends on the stage of the tumor, it is important to pinpoint the stage of the cancer. These include the following criteria:
  • The size of the tumor and its extent within the pancreas or in the adjacent tissue
  • The infestation of local lymph nodes with tumor cells
  • The presence of secondary tumors in other organs

Stages of pancreatic cancer
  • Stage I : Stage I is when the tumor is confined to the pancreas, the lymph nodes in the area are not affected, and there are no metastases in distant organs.
  • Stage II: In stage II, the tumor broke through the boundaries of the pancreas and spread to the surrounding area.
  • Stage III : Stage III is when cells of the tumor have affected the local lymph nodes .
  • Stage IV : In stage IV, secondary tumors are present in other organs (distant metastases).

Surgical measures, chemotherapy and radiotherapy are used to treat pancreatic cancer Pancreatic cancer can only be cured with surgery, often in combination with radiation and chemotherapy (chemoradiotherapy).
The treatment of pancreatic cancer depends on the stage of the disease at the time of diagnosis . It is therefore very important to clarify at the outset by examinations, how extensive the tumor is, whether lymph nodes are affected and whether there are daughter tumors (metastases) in distant organs. Depending on the initial findings, there are different treatment goals: if there is the possibility that the patient can be cured completely, this is called a curative treatment goal (curare = cure).
In advanced stages of disease , which experience has shown to be ineffective in most cases, treatment is aimed at improving the patient's quality of life by alleviating the effects of the condition, such as pain . This is called a palliative treatment.

Curative treatments for pancreatic cancer
  • OP: Only tumors that are confined to the pancreas and have not yet led to lymph node or distant metastases can be operated on for healing . Often, these are incidental findings in studies performed for other reasons. At surgery, the tumor is excised with a safety margin of two centimeters in healthy tissue. Depending on the location of the tumor, parts of the pancreas or the entire gland, possibly including a part of the stomach and duodenum , are removed. A standard procedure is the so-called whipple operationin which the cancerous parts of the pancreas, duodenum and stomach are removed and new connections between the stomach, pancreas, bile duct and small intestine restores the passage of food .
  • Radiochemotherapy: The surgical treatment can be complemented by chemoradiotherapy , a combination of radiotherapy and chemotherapy . The so-called adjuvant chemoradiotherapy is performed following the operation in order to combat tumor remnants and secondary tumors, which may not yet be detectable. In contrast, neoadjuvant chemoradiation is performed prior to surgery to reduce the size of the tumor and thus to achieve a better starting position for the operation.

Palliative treatment for pancreatic cancer

  • OP: In advanced disease stages, the tumor can not be removed surgically. But then there are operational measures available that can improve the quality of life of the patient. This includes, for example, the surgical bridging of bottlenecks in the area of ​​the biliary tract or the duodenum. The bile can also be derived via less invasive measures (endoscopically or percutaneously, see below) via a tumor-related bottleneck.
  • Radiotherapy: Radiotherapy is performed alone or in combination with surgery or chemotherapy. It takes place from the outside over the skin, during an operation or through the operative use of a radioactive substance in the affected tissue. These individual procedures are also combined. Radiation therapy can hardly prolong the survival of the patient with pancreatic cancer, but it can significantly reduce pain in 50 to 70 percent of patients Even in secondary tumors in the bones ( skeletal metastases ) radiotherapy is performed.
  • Chemotherapy: Pancreatic cancer is difficult to influence with medication. Various substances that are effective in the treatment of other types of tumors have been used in pancreatic cancer, singly or in combination, without, however, clearly improving the life expectancy and quality of life of the patients. Since the beginning of 1996, gemcitabine has been used as a treatment for the treatment. Although this substance only slightly improves life expectancy in some of the patients with advanced pancreatic cancer , the quality of life is significantly improved. Recently, gemcitabine has been successfully combined with other drugs, which can extend survival times by a few months.
  • Radiochemotherapy: Radiotherapy and chemotherapy are commonly combined in advanced non-operable pancreatic cancer (chemoradiotherapy). Compared to a single radiation treatment, this can extend the survival time.

Treatment of bile duct closures
If the bile ducts are closed by the tumor, the bottleneck can be bridged by the use of stents (net-like metal or plastic tubes). These are introduced via an optical instrument into the constriction as part of an ERCP or another reflection of the duodenum, so that the bile can flow back into the small intestine . If such an approach is not possible, the pent-up bile can also be discharged through the skin to the outside (percutaneous transhepatic cholangiography or percutaneous biliary drainage).

Pain treatment
Pancreatic cancer, especially in advanced stages, causes severe pain that severely affects the patient's quality of life. Pain therapy is therefore of great importance in this disease. It first takes place with analgesic drugs. If the effect is not sufficient even with the administration of potent opiates ( derivatives of opium ), a peridural anesthesia (PDA) can be performed. In this case, a thin tube (catheter) is advanced via a needle into the spinal canal - usually in the area of ​​the lumbar spine - under local anesthesia.

The catheter, which is adhered to the outside of the patient's dorsal skin, can then be used to inject an anesthetic or an analgesic opiate into the outer tissue layer of the spinal canal . This blocks the nerve roots of the spinal cord nerves so that they no longer transmit the pain stimulus to the brain . The drugs can be delivered via pumping systems evenly into the catheter . At low dosage, only the pain line is turned off, the mobility is maintained. This treatment can also be performed on an outpatient basis, ie without hospitalization.

Nerve blockage against the strongest pain
To control severe pain, the nerve plexus in the upper abdominal area can be blocked by surgery with a high percentage alcohol solution or by the use of a radioactive substance ( plexus-celiac blockade ). This blockade can also be done under computer tomographic control from the outside through the skin. Eighty-five percent of the patients treated receive pain relief, or at least a significant improvement in pain, lasting up to two years.

Treatment in case of functional failure of the pancreas
If the pancreas had to be surgically removed, its functions for digestion and control of carbohydrate metabolism must be replaced. For this purpose, the patient receives at each meal a granule of pancreatic enzymes , which dissolves in the small intestine and there splits the nutrients, so that they can be absorbed into the blood. The most important hormone that makes up the pancreas is insulin . It controls the carbohydrate metabolism and thus the blood sugar level . In case of failure of the pancreas, as with diabetes ( diabetes), Insulin, for example, by being injected twice a day under the skin.

Can you prevent pancreatic cancer?
The prevention of pancreatic cancer has so far only in the prevention of the risk factors secured in a generally healthy lifestyle possible . Safe screening is not available.
Since about 30 percent of cases of pancreatic cancer are due to cigarette smoking , abstaining from smoking is the most important preventive measure.

Stop smoking would prevent nearly 200,000 cases of pancreatic cancer
With ongoing smoking habits , by the year 2020, approximately 627,000 men and 588,000 women in the European Union will get pancreatic cancer. If all smokers stopped immediately , 133,000 men and 43,000 fewer women would contract pancreatic cancer in the same period.

Early detection of pancreatic cancer not possible
Early detection of pancreatic cancer, for example through screening tests, has not been possible until now, as there are no investigational measures to clearly and reliably detect the disease at an early stage.

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