Pancreatic Cancer

Adenocarcinoma of the pancreas

Carcinoma of the /rend of the pancreas. –Although it is often described as a painless condition, yet the patient may present with pain as his first symptom.⁴

Some 90% of pancreatic neoplasm is adenocarcinomas that arise from the pancreatic ducts. These tumors involve local structures and metastasize to regional lymph nodes at an early stage. Most patients have advanced disease at the time of presentation/ when diagnosed.

Neuro-endocrine tumors also arise in the pancreas but tend to grow more slowly and have a better prognosis. Men are affected twice as often as women.¹

The disease is associated with increasing age, smoking, long-standing diabetes, and chronic pancreatitis. Coffee-drinking, alcoholism, and cholelithiasis do not.^{1, 2}

Between 5% and 10%of patients has a genetic predisposition: hereditary pancreatitis, HNPCC and familial a typical mole multiple melanoma syndromes (FAMMM).

Clinical features

The tumors are ductal adenocarcinomas and are not usually detected until the disease has spread. About 70% of tumors are in the pancreatic head, 20% in the body, and 10% in the tail.^2,3

It is a very aggressive neoplasm.³

1. Many patients are asymptomatic until an advanced stage, when they present with central abdominal pain, weight loss and obstructive jaundice. ^{1, 2, 3}
2. The abdominal pain results from invasion of the coeliac plexus and is characteristically incessant and gnawing.^{1, 2, 3.}Pain often radiates from the upper abdomen through to the back and may be eased a little by bending forwards. Almost all patients lose weight and many are cachectic.^{1, 2}
3. Dyspepsia and early satiety may be present due to delayed gastric emptying (gastro paresis). Vomiting may be present if the tumor has invaded or compressed the second portion of the duodenum, creating a partial or complete intestinal obstruction.
4. Around 60% of tumors arise from the head of the pancreas, and involvement of the common bile duct results in the development of obstructive jaundice, often with severe pruritus.^{1, 2}
5. Venous thrombosis, acute pancreatitis or depression are other common findings.

Signs on examination

Physical examination reveals clear evidence of weight loss. Anabdominal mass due to the tumor itself, a palpable gall bladder or hepatic metastasis is commonly found. A palpable gall bladder in a jaundiced patient is usually the consequence of distal biliary obstruction by a pancreatic cancer.¹

Other findings include left supraclavicular lymphadenopathy (Virchow’s node) and superficial thrombophlebitis (Trousseau’s sign).³

Investigations

The diagnosis is usually made by ultrasound and contrast enhanced CT. Diagnosis in non-jaundiced patients is often delayed because presenting symptoms are relatively non-specific. Fit patients with small, localized tumors should undergo staging to define operability.¹

Features on CT scan include alterations in morphology of the gland with abnormalities of CT attenuation values, obliteration of peripancreatic fat, loss of sharp margins with surrounding structures, involvement of adjacent vessels and regional lymph nodes, pancreatic ductal dilatation, pancreatic atrophy, and obstruction of the common bile duct. Tumors less than 1 cm are readily visualized with EUS.³

EUS or laparoscopy with laparoscopic ultrasound will define tumor size, involvement of blood vessels and metastatic spread. In patients unsuitable for surgery because of advanced disease, frailty or co morbidity, EUS- or CT-guided cytology or biopsy can be used to confirm the diagnosis. MRCP and ERCP are sensitive methods of diagnosing pancreatic cancer and are valuable when the diagnosis is in doubt, although differentiation between cancer and localized chronic pancreatitis can be difficult. The main role of ERCP is to insert a stent into the common bile duct to relieve obstructive jaundice in inoperable patients.^{1, 3}

The lesion may have a variable appearance on ultrasonography; it may be hypoechoic, isoechoic, or hyperechoic as compared to normal pancreas. Pancreatic ductal dilatation and biliary ductal dilatation are easily demonstrated in patients with a tumor in the head of pancreas. Lymphadenopathy, relation of the tumor to peripancreatic vessels, and the tumor margins are demonstrated less reliably with sonography. CECT scan of abdomen using a pancreas protocol is the most useful and widely used imaging modality especially when some intervention is planned.³Serum carbohydrate antigen (CA) 19-9 has an overall sensitivity of approximately 80% and specificity of 90%.³

Conventional Treatment Management

Surgical resection is the main method of effecting cure, and 5-yearsurvival in patients undergoing a complete resection is around 12%. Clinical trials have demonstrated improved survival (21–29%) with adjuvant chemotherapy.

For the great majority of patients, treatment is palliative.³If the primary tumor is less than 3 cm free of major blood vessels and if there is no metastatic spread. Suitable patients undergo Whipple’s procedure, which involves excision of the head of the pancreas, the distal common bile duct, the gall bladder, the duodenum and distal stomach, followed by anastomosis of the pancreatic duct, the common hepatic duct, and the distal stomach to a loop of jejunum. Perioperative mortality is less than 5% in experienced hands. Modified Whipple’s procedure involves preservation of the distal stomach and pylorus, which may have long-term nutritional benefits. Distal pancreatectomy may be suitable for carcinoma of the body or tail.³

Diet Guidelines⁵

• Healthy weight should be maintained
• Frequent meals in small quantity throughout the day
• Drinking plenty of water
• Changes in bowel habits should be observed
• Foods should be consumed that are easily digestive
• Protein-rich foods should be taken

Homeopathic Management

Homeopathic medicines play role as a palliative therapy in pancreatic cancer. Use of homeopathy has been shown to increase the life expectancy and life condition of the patient. A study by Christopher Johnson attempts and indicates use of homeopathic to be of benefit for Pancreatic cancer but definitely more studies are need to establish role of homeopathy.

Homeopathy can help in improving the general well being and vitality of the patient. Homeopathic medicines can be given as an adjunct to conventional treatment. It can help prolong the life and improve the overall life condition of the patient.

Homeopathic Medicines¹⁰