Pancreas is a 12-15 cm long and 2.5 cm wide fish-like organ that consists of a wide head, a tapering body, and a narrow tail. It is situated behind the stomach with its head connected the duodenum (the initial portion of the small intestine) via two ducts: the pancreatic duct and the accessory duct.
It is made up of mainly 2 types of cells – the exocrine cells (99%) and the endocrine cells (1%). The main functions of the pancreas include secretion of digestive juice and several hormones (glucagon, insulin, somatostatin, and pancreatic polypeptide).
Pancreatic adenocarcinoma (affecting exocrine cells) is the most common (95% of the cases) type of pancreatic cancer.
What is the Staging of Pancreatic Cancer?
To understand the staging better, let’s have a look at the normal anatomy of the pancreas.
Below is a diagram showing various parts of pancreas, including head, neck, body and tail. Projection from the head is called as uncinate process.
Duodenum curves along the head of the pancreas. Main pancreatic duct and Bile duct pass through the pancreas to join the duodenum.
This figure shows the arterial supply with celiac artery giving rise to common hepatic artery and splenic artery above the pancreas. Superior pancreatic artery passes from behind.
Superior mesenteric vein joins the splenic vein to form portal vein in front of the neck of pancreas.
Staging for pancreatic cancer is called as TNM staging system. It helps in disease prognostication and choosing an appropriate treatment strategy.
T1 – Tumor is less than 2 cm in size.
T2 – Tumor is 2 to 4 cm in size.
T3 – Tumor is more than 4 cm in size.
Tumor may be limited to any part of the pancreas, or it may even extend outside to invade the adjacent structures.
Like in the figure below, tumor in pancreatic head invades the duodenum.
And here, tumor in tail of pancreas invades the spleen.
It may also infiltrate into the suprarenal gland.
Tumor may invade the splenic vein.
Or portal vein.
Splenic artery may be involved by the tumor.
So may be the superior mesenteric artery.
T4 – In this, pancreatic tumor may infiltrate into common hepatic artery, celiac artery or superior mesenteric artery.
This figure shows, superior mesenteric artery infiltration.
And here, tumor involves celiac artery.
It may also infiltrate into common hepatic artery.
N0 – No regional lymph nodes involved by cancer
N1 – Regional lymph nodes involved by cancer
M0 – Cancer has not spread to distant sites.
M1 – Distant organs may be involved such as lungs, bones, liver, peritoneum, brain, etc
Like in this figure, peritoneal metastasis has resulted in multiple peritoneal deposits.
This figure shows cancer spread to liver.
And here, cancer has spread to both the lungs.
What is the Stagewise treatment of Pancreatic Cancer?
Treatment of pancreatic cancer depends on the stage, resectability, performance status of the patient, along with other factors. But the final treatment decision is taken by the oncologist after clinical evaluation of the patient.
Non-Metastatic Pancreatic Cancer
Treatment of non-metastatic pancreatic cancer depends on whether the disease is Resectable, Borderline Resectable or Unresectable
It includes the cases that are localised to pancreas, or infiltrate into duodenum, spleen or left kidney or suprarenal gland. Superior mesenteric vein or portal vein involvement may be resectable only in selected cases.
Surgical Resection is the treatment of choice for resectable disease, with addition of chemotherapy in high-risk cases.
Borderline Resectable Disease
Common hepatic artery involvement by tumor is included in this. Depending on the extent of involvement, invasion of superior mesenteric artery, celiac artery, superior mesenteric vein or portal vein may be considered borderline resectable.
In such cases, chemotherapy with/without radiotherapy is given and then decision for surgery is taken depending on response to treatment.
Depending on the extent of involvement, invasion of superior mesenteric artery, celiac artery, superior mesenteric vein or portal vein may be considered unresectable.
Chemotherapy with/without radiotherapy is the preferred treatment in such cases.
Metastatic Pancreatic Cancer
Chemotherapy, immunotherapy and/or targeted therapy is the standard treatment for metastatic disease. Radiation therapy, surgery, or other modalities may be used for palliation or relief of symptoms.
What is the role of Surgery in Pancreatic Cancer treatment?
Surgery provides significantly longer survival and is considered as the treatment of choice for resectable pancreatic cancers. Radical pancreatic resection such as Whipple procedure (resection of pancreas and duodenum), partial, or complete pancreatic resection are some common surgical procedures employed with a curative intent for resectable and borderline resectable pancreatic cancers.
For unresectable pancreatic cancers, surgery is employed for palliation of symptoms, which may include biliary/gastric bypass surgery and biliary stent placement to relieve bile duct blockage.
Is Immunotherapy an option for Pancreatic Cancer treatment?
Pembrolizumab had been granted US FDA approval for the treatment of MSI-H or dMMR positive unresectable/metastatic pancreatic cancers that have progressed on prior treatment and for which no satisfactory alternative treatment option is available.
What Targeted Therapy is available for Pancreatic Cancer treatment?
Targeted drugs work differently than chemotherapy drugs that they target a specific gene or protein characteristic of the pancreatic cancer cells, for example, erlotinib targets epidermal growth factor receptor (EGFR). They are generally used alone or in combination with chemotherapy for the treatment of advanced disease.
Best Pancreatic Cancer Specialist in Delhi
Dr Sunny Garg is a renowned Medical Oncologist in New Delhi with an experience of more than 6 years of treating pancreatic cancer patients. He has practiced in leading cancer hospitals in Delhi, and currently practicing at Manipal Hospital, Dwarka.
He has a vest experience of treating pancreatic cancer patients in all stages of disease. He is well versed with Immunotherapy, Targeted Therapy and Chemotherapy for Pancreatic Cancer treatment and also general supportive care for patients. He works in close collaboration with surgical and radiation oncologists, oncopathologists, nuclear medicine, and genetic counselors for comprehensive cancer care for the patients.
Call +91 9686813020 for appointment.