Pancreatic adenocarcinoma
What is it?
Adenocarcinoma of the pancreas accounts for 3% of all new cancer cases and the fourth leading cause of cancer death in both sexes and the incidence is increasing continuously in recent years. With a 5-year survival rate of 8% and a 10-year survival rate of 3% and therefore pancreatic adenocarcinoma remains one of the most unfavorable prognosis tumors. This is due to the biological aggressiveness of the neoplasm itself and to diagnosis at an advanced stage of the disease. Cigarette smoking, dietary factors and lifestyle habits and organ pathologies are recognized risk factors. About 5-10% of pancreatic cancers are due to hereditary genetic alterations (e.g. pathogenic BRCA2 mutation). Genetic testing for BRCA gene mutations should be offered to all patients diagnosed with pancreatic cancer and younger than 74 years of age.
Which are the symptoms?
Diagnosis is often late because symptoms are vague and nonspecific. Tumors of the body and tail of the pancreas are diagnosed later than head tumors, which more frequently cause obstructive jaundice due to the mass effect of the neoplasm on the biliary tract. The clinical picture may be characterized by:
- abdominal bar pain
- weight loss
- jaundice (for head tumors)
- steatorrhea
- new onset diabetes
- symptoms of gastroduodenal obstruction
How is it diagnosed?
Usually, the patient who complains of symptoms has to undergo a transabdominal ultrasound, which raises the suspicion of pancreatic neoplasia. A computerized axial tomography (CT) of the chest and abdomen with intravenous contrast medium is then performed, which is essential for the identification of the tumor, the study of its relationships with neighboring organs and structures and its eventual surgical resectability, as well as the absence or presence of distant metastatic lesions.
In particular, for the study of the possible presence of liver metastases, a Nuclear Magnetic Resonance with hepatospecific contrast medium can be performed to clear the suspicion and increase the possibility of liver staging diagnosis.
Therefore, the diagnostic test par excellence is the echo-endoscopy, which allows an accurate and sensitive staging of the neoplasm at local level and of possible lymphadenopathies and, very important, allows a typing of the same, through the execution of a biopsy by needle aspiration and cyological analysis (there is always a cytotechnician in the room that evaluates the amount of aspirated material if sufficient for a correct diagnosis).
Among the laboratory tests, CEA and Ca19.9, two tumor markers correlated with pancreatic cancer, are also dosed in the blood. Their values can be increased (Ca19.9 is particularly increased in 80% of patients in advanced stages) at diagnosis and can represent a control guide for the response to treatments.
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How is it treated?
The definition of the correct therapeutic strategy requires a specialized multidisciplinary team that includes: surgeons, medical oncologists, gastroenterologists, radiation oncologists and radiologists and palliative care specialists.
In patients with localized pancreatic cancer that does not infiltrate the surrounding vascular structures, surgical resection is indicated and should be performed in high/very high volume centers of pancreatic surgical resections so as to greatly reduce the rate of complications that can occur in this type of major surgery. The indicated interventions are duodenocephalopancreasectomy, distal pancreasectomy, or, more rarely, total pancreasectomy. These may be preceded or followed by chemotherapy and/or radiation treatment with the goal of reducing the size of the neoplasm, eliminating any distant micrometastases, and reducing the risk of local and/or distant recurrence. However, at diagnosis less than 20% of patients have a resectable tumor.
When the tumor is localized to the pancreas but surgery is not indicated because of the relationship of the neoplasm with the vascular structures, chemotherapy is indicated, possibly followed by concomitant chemo-radiotherapy.
If the tumor is not surgically resectable, it is possible to treat the symptoms caused by the neoplasm endoscopically and minimally invasively as in the case of obstructive jaundice (placement of biliary stents, hepaticodigiunostomies or gastrodigiunostomies under ecoendoscopic or surgical guidance).
In patients with metastatic pancreatic cancer, systemic chemotherapy remains the standard of care.
In resectable pancreatic cancer, postoperative adjuvant radiotherapy may be considered for positive lymph node metastases or resection margins. Radical radiotherapy is indicated in patients with unresectable disease. The available technologies, capable of obtaining a high dose conformation with consequent saving of the surrounding risk organs, have made it possible to develop hypofractionation protocols in 15 fractions. Currently, disease control even in advanced cases with combined treatment is around 27 months. In selected cases it is possible to use a hypofractionation with stereotaxic technique in 5 sessions for curative or even symptomatic purposes.
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Where do we treat it?
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