Pancreatic Cancer Surgery in India

Overview:
The pancreas is a small organ which plays a big role in our body. It is situated near the liver which produces enzymes that help in digestion of food, and also helps to maintain the sugar levels in the body. Insulin is the hormone produced by the pancreas, which helps in balancing the level of glucose in the blood. Pancreatic tumour is a growth of tissue that forms an abnormal mass known as neoplasm. There are no useful functions for tumors and they grow at the expense of healthy tissues. Pancreatic tumor never gets detected till the late stage. Since pancreas is a tiny organ and the place it is situated is tricky it can cause trouble to the other vital organs. Most pancreatic cancers begin in the ducts that carry pancreatic juices. Cancer of the pancreas may be called pancreatic cancer or carcinoma of the pancreas. A rare type of pancreatic cancer begins in the cells that make insulin and other hormones. Cancer that begins in these cells is called islet cell cancer.



Symptoms of Pancreatic Cancer:
The most common early symptoms can include:

• Pain in stomach area that may spread to your back
• Jaundice
• Unexplained weight loss 

Other and later symptoms

• Bowel disturbances 
• Nausea 
• Fever and shivering 
• Diabetes

Types of Pancreatic Cancer:
There are two types of pancreatic cancer, that of the exocrine gland and that of the endocrine gland. About 95 percent of pancreatic cancers begin in the exocrine cells of the pancreas.

• Exocrine tumors:  Most tumors affecting the exocrine gland are called adenocarcinomas. This type of cancer forms in the pancreas ducts. Treatment for these tumors is based on stage of growth.
  
  
• Ductal Adenocarcinoma - Adenocarcinomas account for over 75% of all pancreatic cancers, and develop from cells that line the ducts which carry the digestive juices into the main pancreatic duct and then into the duodenum. They can develop anywhere within the pancreas. Most commonly, they are found in the head of the pancreas.
  
  
• Acinar Cell Carcinoma - This is a very rare cancer (about 1% of pancreatic cancers) and develops in the acinar cells that produce and secrete the digestive enzymes. These tumours may produce excessive amounts of the digestive enzymes and so cause distinct symptoms including unusual skin rashes and joint pain.
  
  
• Adenosquamous Carcinoma - These tumours are similar to adenocarcinomas in that they form in glands, but the cells flatten as they grow.
  
  
• Intraductal Papillary Mucinous Neoplasm/Tumours - Also known as IPMNs (or IPMTs), they form in the main pancreatic duct or in its side branches. They form finger like projections known as papillae into the duct and secrete a large amount of mucous which often causes the duct to expand or dilate. They account for about 3% of cases. They may be benign when first diagnosed but if left unchecked will change into a more aggressive and invasive form of cancer.
  
  
• Mucinous Cystadenocarcinoma - A rare malignant cyst filled with mucin - a thick gel like fluid - predominantly affecting the tail of the pancreas and not the ductal system. They account for 1 - 2% of exocrine tumours and almost exclusively are found in women (middle-aged). If the cyst (which can grow very large -up to 20 cm) presses on the bile duct it will cause obstructive jaundice.
  
  
• Pancreatoblastoma - A very rare childhood tumour (predominantly found in children under 10) that is even more rarely seen in adults. Mainly made up of acinar cells, some show ductal elements and even endocrine cells. Its features overlap those of acinar cell carcinoma.
  
  
• Serous Cystadenocarcinoma - A cyst filled with thin watery fluid. These are almost always benign tumours which although can grow quite large, do not spread to other parts of the body. Cystic tumours represent about 2% of all pancreatic cancers. Most are benign, but their growth will impact on other structures and cause symptoms such as jaundice if they press on the bile duct.
  
  
• Solid and Pseudopapillary Tumours - These are rare, benign or low grade malignant tumours more commonly seen in girls and young women. They can occur anywhere but most frequently they are found in the tail and consist of both solid and cystic parts. They have a good prognosis if they can be completely removed since they can spread.
  
  
• Endocrine Tumors:  These tumors are less common and are most often benign. Though rare, cancer stemming from an endocrine tumor (cystadenocarcinoma) affects the hormone-producing cells. There are different types of Endocrine tumours.
  
  
• Gastrinomas (Zollinger-Ellison Syndrome) - These produce too much gastrin, causing peptic ulcers in the stomach or duodenum. This leads to severe pain, bleeding causing black tarry stools (faeces), and diarrhoea. They occur in the pancreas and in the duodenum. These tumours are mostly malignant, meaning cancerous. The majority of cases appear to develop for unknown reasons, but about 25% of cases are associated with the MEN-1 syndrome, and as such are inherited as part of a genetic syndrome. Improved early screening in at risk groups may lead to earlier diagnosis when the tumours are still benign.
  
  
• Glucagonomas - These produce too much of a hormone called glucagon. This causes a very specific type of skin rash (redness, ulceration and scabbing), anaemia, mouth ulcers and diarrhoea. These tumours are mostly malignant, meaning cancerous. 
  
  
• Insulinomas - These produce too much insulin, causing weakness, loss of energy, dizziness and drowsiness. These tumours are nearly always benign, meaning non-malignant and non-cancerous. Insulinoma is the most common and well-known islet cell tumour of the pancreas, accounting for more than 75-80% of sporadic functioning pancreatic islet cell tumours. 
  
  
• PPomas - These are also usually malignant, meaning cancerous. 
  
  
• Somatostatinomas - Produces too much of a hormone called somatostatin. This causes gall stones, diabetes and diarrhoea with bulky fatty and smelly stools (steatorrhoea). These tumours are mostly malignant, meaning cancerous.
  
  
• VIPomas - Produces too much of a hormone called VIP. This causes a great deal of watery diarrhoea, flushing of the face, and high blood pressure. These tumours are mostly malignant, meaning cancerous.

Causes of Pancreatic Cancer:
The exact cause is unknown.

Diagnosis of Pancreatic Cancer:
The doctor may perform a number of procedures, including one or more of the following to confirm the cancer:

• Physical Exam - The doctor examines the skin and eyes for signs of jaundice. The doctor also examines the abdomen to check for changes in the area near the pancreas, liver, and gallbladder and to check ascites.
  
  
• Lab Tests - The doctor may take blood, urine, and stool samples to check for bilirubin and other substances. Blockage by a tumour may cause the level of bilirubin in the blood, stool, or urine to become very high. High bilirubin levels can result from cancer or from noncancerous conditions.
  
  
• CT Scan (Computed Tomography) - An x-ray machine linked to a computer takes a series of detailed pictures. The computer puts the x-rays together to create pictures of the pancreas and other organs and blood vessels in the abdomen.
  
  
• Ultrasonography - The ultrasound procedure may use an external or internal device, or both types:
  
  
• Transabdominal Ultrasound - To make images of the pancreas, the doctor places the ultrasound device on the abdomen and slowly moves it around.
  
  
• EUS (Endoscopic ultrasound): The doctor passes a thin, lighted tube (endoscope) through the patient's mouth and stomach, down into the first part of the small intestine. At the tip of the endoscope is an ultrasound device. The doctor slowly withdraws the endoscope from the intestine toward the stomach to make images of the pancreas and surrounding organs and tissues.
  
  
• ERCP (Endoscopic Retrograde Cholangiopancreatography) - The doctor passes an endoscope through the patient's mouth and stomach, down into the first part of the small intestine. The doctor slips a smaller tube (catheter) through the endoscope into the bile ducts and pancreatic ducts. After injecting dye through the catheter into the ducts, the doctor takes x-ray pictures. The x-rays can show whether the ducts are narrowed or blocked by a tumor or other condition.
  
  
• PTC (Percutaneous Transhepatic Cholangiography) - A dye is injected through a thin needle inserted through the skin into the liver. Unless there is a blockage, the dye should move freely through the bile ducts. The dye makes the bile ducts show up on x-ray pictures. From the pictures, the doctor can tell whether there is a blockage from a tumor or other condition.
  
  
• Biopsy - In some cases, the doctor may remove tissue. A pathologist then uses a microscope to look for cancer cells in the tissue. The doctor may obtain tissue in several ways. One way is by inserting a needle into the pancreas to remove cells. This is called fine-needle aspiration. The doctor uses x-ray or ultrasound to guide the needle. Sometimes the doctor obtains a sample of tissue during EUS or ERCP. Another way is to open the abdomen during an operation.

Risk Factors of Pancreatic Cancer:

• Obesity
• Smoking habits
• Common in women
• Aging
• Genetic

Stages of Pancreatic Cancer:
 The pancreatic cancer has a four stage cycle;

Stage 1: Also called as resectable stage in which cancer is localized and in its formative stage inside the pancreas itself. The size of the cancer may be large. This stage also indicates that the cancer has still to make its entry into the lymph node in the vicinity of the pancreas and it has not spread its tentacles to other parts of the body.

Stage -2: Also referred to as the locally advanced cancer, the cancer has spread to duodenum or the bile duct and has invaded other tissues and organs situated next to the pancreas, but the cancer has not spread into lymph nodes situated nearby.  

Stage 3: Also called as the metastatic cancer. It may have acquired any size and could have made inroads into the tissues which engulf the pancreas from all the sides or the distant parts of the body like the lungs, liver or abdomen.

Stage 4: This stage is further sub-divided into two stags, 4A and 4B. This stage is also referred to as the recurrent stage during which the cancer may have affected the nearby organs like the stomach, spleen, large bowels or the nearby large blood vessels. When it is 4B stage, it means that cancer has spread its tentacles far and wide and has reached the lungs or the liver.

Pancreatic Cancer Surgery:
Surgical treatment for pancreatic cancer falls into two main categories.

• Curative Surgery
• Palliative Surgery

Curative Surgery - If the tumour is small, there are no signs that it has spread, surgery is considered the most effective treatment option. Depending on where the cancer is and how much of the pancreas is involved, potentially all or just part of the pancreas will be removed 

• Whipple's Operation – This operation involves the removal of the head of the pancreas, the lower end of the stomach, most of the duodenum (first part of the small intestines), the common bile duct, gall bladder and the surrounding lymph nodes. The remaining part of the stomach, bile duct and pancreas are then reattached to the small intestines. 
  
  
• Pylorus-preserving Pancreatoduodenectomy; At times, it is not necessary to remove the lower end of the stomach thus preserving the stomach valve (the pylorus) that empties into the small intestines. 
  
  
•  Distal Pancreatectomy - also called 'left' pancreatectomy, it is performed on the tail end or body of the pancreas which is furthest away from the join to the duodenum
  
  
• Total Pancreatectomy - sometimes it is necessary to remove the whole pancreas if there is a large cystic or endocrine tumour.

Palliative Surgery - If the cancer has spread and cannot be removed, there are a number of operations that might be recommended by your doctor to help alleviate some of the symptoms of the disease. The most common symptoms that need surgical intervention are jaundice, bowel obstruction and pain. The blockage due to tumour in the duct can be treated a number of ways

• Insertion of a plastic or metal tube called a stent - Usually this can be inserted endoscopically while the patient is sedated.
  
  
•  Biliary Bypass - Choledocho-Jejunostomy - if placing a stent is not possible, an operation that allows the bile to drain away by bypassing the blockage can be performed. it is where the bile duct is cut above the blockage and then reattached directly into the small intestines.

• Gastric Bypass - The upper part of the small intestines - the duodenum - can become blocked by the tumour. In this surgery the duodenum below the blockage is attached directly to the stomach allowing the food to pass through into the bowels and relieves bowel obstruction.

• Coeliac Plexus Nerve Block -The nerves from the pancreas collect just behind it in a thick bundle called the Coeliac Plexus. By injecting a special chemical directly into this nerve plexus you may receive pain relief.

Chemotherapy for Pancreatic Cancer:
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. 



Radiation Therapy for Pancreatic Cancer:
Radiation therapy is a cancer treatment that uses high-energy radiation beams to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.



Follow-Up Treatment for Pancreatic Cancer:
Regular examinations are necessary to determine whether the cancer has returned or has advanced. Many of the same methods used to diagnose the cancer may be used to evaluate the patient's recovery. These may include CAT scans, MRI tests, and X-rays, among others. In addition, the treatment team will need to monitor the patient's hormone replacement therapy or other ongoing treatments. 

Benefits of Pancreatic Cancer Surgery:
Although many of the treatments can cause side effects, these can usually be well controlled with medicines. Treatment can be given for different reasons, and the potential benefits will vary depending upon each person's situation. Treatment does positive results through the use of surgery, radiation or chemotherapy. If diagnosed early, cancer treatments encourage eradication of tumors and cancerous tissues and may increase positive prognosis. Treatments of Pancreatic cancer help patient receive relief from painful symptoms, thus help them lead a better life.


Pancreatic Cancer Surgery in India:
In India there are numerous hospitals available which specializes in different types of cancer treatments including treatment of Pancreatic Cancer. The specialists in these hospitals are well trained in the field of ocology and surgery. The level of healthcare services in the leading hospitals and medical centers of India are ‘on par’ to what is being offered in US and UK. India offers several hospitals and medical centers that are known widely for its best medical and health care services in wide variety of specialty fields. The physician and surgeon handle many cases every day and have acquired a skill in operating different difficult and complicated surgeries. Most hospitals use advanced methods of therapy for all cancer treatments.

Cities in India that offers Pancreatic Cancer Surgery in India are as follows;