What is the pancreas?

The pancreas is an organ, around 15cm in length, which sits deep inside the upper aspect of the abdomen (tummy). It has many important functions, including the production of essential hormones such as insulin, and helps in the digestion of food by making the necessary digestive enzymes.

The pancreas can be divided into head, neck, body and tail as shown in the diagram. As can be seen from the picture the pancreas is surrounded by several organs including first part of the small bowel (duodenum), the bile duct and gallbladder, part of the stomach, etc.

What is pancreatic cancer?

Pancreatic cancer occurs when a group of cells inside the pancreas start to multiply on their own and lose control from the mechanisms which would usually keep them at bay. The cancerous (malignant) cells become a lump (or growth). The cancer can grow to a large size before its presence is suspected, also depending on which part of the pancreas is affected.

Worldwide, pancreatic cancer is the 10th most common cancer, but it is the third leading cause of cancer death. The reported frequency is 13 new cases per 100,000 persons each year.

What are the signs and symptoms of pancreatic cancer?

As can be expected, the earlier the cancer is noticed, the higher the chance of a cure. If the cancer occurs in the head of the pancreas, it might block the common bile duct and in this case the patient will present with jaundice, which is a yellowish discolouration of the skin. This happens because the common bile duct carries a substance which is produced by the liver to the bowels.

This substance (bile) gives the brownish colour to our stools. If the bile duct becomes blocked by cancer (amongst other things), the substance stays in the body and causes the skin and eyes to become yellow. Furthermore, since bile does not pass through the bowel as usual the stools become whitish and pale, whilst the uring becomes darker (typically called Kinnie coloured here in Malta).

When bile accumulates in the body, the patient will usually experience itching, which can be very troublesome. Tummy pain might also be the presenting feature of pancreatic cancer. A sudden appearance of diabetes (or deterioration of glucose levels) in someone with tummy pain should also raise the possibility of pancreatic cancer.

There are no blood tests specific to pancreatic cancer, but there are some markers which will need further attention. The liver produces some substances, and when these are raised (known as raised liver function tests) this might mean there is a blockage, one cause of which is pancreatic cancer.

Risk Factors

These include smoking, obesity, alcohol abuse, older age, and chronic inflammation of the pancreas, called chronic pancreatitis. Living a healthy lifestyle therefore reduces the chances of developing pancreatic cancer.

A strong family history of pancreatic cancer also predisposes one to a higher chance, and in such an instance screening for this cancer should be carried out.

Investigations

When a diagnosis of pancreatic cancer is suspected, a patient will undergo several scans, which typically include, Ultrasound, CT scan and MRI scan of the tummy, with the aim of confirming or excluding the presence of such a problem.

Treatment

Once the presence of pancreatic cancer is confirmed, each case will be discussed in a multidisciplinary meeting, where different specialists including nurses, surgeons, oncologists, radiologists and gastroenterologists gather together to study the best course of action for each patient.

When the tumour is confined to the pancreas, surgery to remove it will be considered.

Such operations are complex operations which require a great effort by the specialists involved. However these procedures are done routinely at Mater Dei Hospital, on a weekly basis

The type of operation will depend on the location of the tumour. When the tumour is in the head of the pancreas, a Whipple’s procedure is usually done. This involves removing half of the pancreas, the first part of the small bowel (the duodenum), a small part of the stomach, the gallbladder and the bile duct, and rejoining everything together.

When the tumour is in the body and tail of the pancreas, this part of the pancreas will be removed, together with the spleen in most instances. In some other situations, the entire pancreas is removed.

In those cases where pancreatic cancer is removed with an operation, cure is possible, even long term cure.

One must understand that these operations are done with curative intent, meaning that the aim of such surgery is to cure the patient from his or her disease.

Often after such surgery, the patient will require to have chemotherapy, with a view to reduce the chance of this disease reappearing. In some instances chemotherapy is given before the operation to shrink the tumour to make its removal possible.

A proportion of patients will not be offered surgery as their disease is not amenable to surgery either because it is involving surrounding organs or has spread to the liver, lungs or other organs. In these circumstances, chemotherapy may be offered.

Prognosis

When pancreatic cancer is discovered early and surgery is successful, cure is possible. The most important thing from all the above is that when a patient feels any of the above or is uncertain about something, a consultation with a doctor should be made who can then refer to further specialist service.

Mr Noel Cassar is a Consultant Surgeon with Special Interest in Hepatobiliary Surgery at Mater Dei Hospital.

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