Pancreatic Cancer

The pancreas is a gland located deep in the abdomen between the stomach and the spine, connecting the duodenum. It is a digestive organ, mainly for the secretion of digestive enzymes to help digestion, and the manufacturing of insulin to monitor the blood sugar level.

Pancreatic cancer is an aggressive cancer. As the malignant tumour within the pancreas grows slowly, and hides itself deep, it is not easy to detect at its early stage. Even though for a person who has regular checks annually, it is difficult to find out if the person has got the pancreatic cancer through general tests. Therefore, pancreatic cancer is usually diagnosed at advanced stage and so delays the necessary treatments and has poor survival rate. Even the patient is able to undergo surgery to remove the tumour, his/her life span is still shorter than that of other cancer patients.

Most patients of pancreatic cancer are over the age of 65, and the other risk factors include:

• Male.
• Race: black people.
• Smokers’ chance of getting the disease is 2 to 3 times higher than that of non-smokers.
• Overweight.
• A prolonged over intake of animal fat and poor vegetable and fruit consumption.
• Abnormal sugar metabolism such as diabetes mellitus.
• Prolonged contacts with chemicals such as pesticides, petroleum or dyes.
• Infection with Helicobacter pylori, the risk for people infected with the bacteria is 2 times higher in getting the disease.
• Hereditary chronic pancreatitis will add the risk of getting pancreatic cancer, but it seldom occurs.
• Chronic pancreatitis is usually discovered together with pancreatic cancer, but the former may not be the cause of the latter.

Should a patient have the following symptoms, he/she may get the disease:

• Sustained pain in the upper abdomen, which is not related to eating or drinking, and the pain may extend to the back.
• Loss of appetite, nausea, vomiting, indigestion, physogastry, and other intestine and stomach problems.
• Jaundice, itching skin and clay coloured stools.
• Drastic loss of weight in a short time.
• Fixed, hard lumps in upper abdomen.
• Ascites.

While it is not clear what causes pancreatic cancer, some risk factors identified are:

• Smoking
• Overweight or obesity
• Consumption of red or processed meat
• Heavy alcohol consumption
• Elderly males
• Family history of pancreatic cancer and carrier of certain inherited genes
• History of certain diseases (e.g. diabetes mellitus, chronic or hereditary pancreatitis)

The general public should adopt the following healthy lifestyle and behavioural changes to prevent pancreatic cancer:

• Do not smoke, or quit smoking if one has already been smoking
• Avoid alcohol consumption, and
• Maintain a healthy body weight and waist circumference by being physically active and adopting a healthy eating pattern that includes plenty of fruits, vegetables, and whole grains, and that limits or avoids red and processed meats, sugary beverages, and highly processed foods

Based on the available international and local scientific evidence, the Government’s Cancer Expert Working Group on Cancer Prevention and Screening has made the following recommendations on pancreatic cancer screening for the local population:

For persons at average risk

Screening for pancreatic cancer (including screening by serum biomarker CA19-9) is not recommended in asymptomatic persons at average risk.

For persons at increased risk

There is currently insufficient evidence to recommend screening of pancreatic cancer for persons at increased risk by any standardised protocol. Persons with strong family history of pancreatic cancer, specific genetic syndromes, or carrying genetic susceptibility traits that put them at significantly increased risk of pancreatic cancer may consider seeking advice from doctors for individual assessment.

After taking patient's history and suspected he/she has pancreatic cancer, the doctor will arrange the following tests to explore the size and location of the tumour.

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   Ultrasound

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   Abdominal computerized tomography scan

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   Abdominal magnetic resonance imaging

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   Endoscopic retrograde cholangiopancreatography (ERCA)

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   Percutaneous transhepatic cholangiogram (PTCA)

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   Biopsy

   Using Fine Needle Aspiration (FNA) Cytology, the doctor employs a thin needle to penetrate the wall of duodenum using the guidance of endoscopic ultrasound to reach tumour site. The samples of cells will be sucked through the needle and the sample tissues will be examined under the microscope to make diagnosis.

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   Blood test

   Blood marker carbohydrate antigen 19-9 (CA 19-9) is elevated in some patients with pancreatic cancer. It may play a role in disease monitoring and prognosis, together with radiological/imaging and clinical data. However, it can be elevated in other biliary conditions such as cholangitis, biliary obstruction of other aetiologies, and some other types of cancers.

Treatments for pancreatic cancer depend on the stage of the cancer, the age of the patient, the overall health conditions and patient’s preference. In response to these factors, the goal of tumour treatment is to eliminate the tumour, or to slow down the growth of the tumour wherever possible or to avoid causing further damages. Therefore, under certain circumstances, palliative treatment may be most suitable to individual patient.

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   Surgery

   At present, removing the tumour completely through surgery is the only mean of eliminating pancreatic cancer thoroughly, but this is not applicable to all the patients, especially when the cancer cells have spread beyond the pancreas to other organs and affected the lymph nodes and major blood vessels extensively.

   Whipple’s operation is the most commonly used surgery technique which includes the removal of the pancreas, duodenum, gall bladder and even part of the stomach, etc. The death rate caused by surgery is lower than 5%.

   Around 25% of the patients have pancreatic cancer located in the body and tail of the pancreas. Depending on the tumour condition, they may need to undergo distal pancreatectomy or total pancreatectomy.

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   Radiotherapy

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   Target therapy

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   Palliative treatment

   If the cancer has spread extensively, the primary objective is to mitigate the symptoms and maintain the patient’s quality of life.

   • Palliative shunt: If the tumour blocks the bile duct, a stainless steel or plastic stent is inserted in the bile duct, so as to maintain free flowing in the duct. If the intestine is blocked, by-pass surgery may be deemed necessary.
   • Pain treatment: This may be the case in the advanced stage when the tumour compresses against surrounding nerves, which results in severe pain. Morphine can be useful in this stage. When usual drug fails to function efficiently, the patient may be consulted on other choices, such as using drugs to stop the pain signals from being transmitted or injecting alcohol into the nerves to destroy the pain reception.

The following complications may occur to patients with pancreatic cancer:

• Jaundice.
• When tumour enlarges and presses the nerves, it will intensify abdominal pain.
• Sever loss of weight. Patients having difficulties in eating may need to be fed with a nasogastric tube or through intravenous injection to insert nutrition supplements.

Pancreatic cancer operations are very difficult to perform, but the survival rate has improved a lot. Complications include bleeding, infection and unstable blood sugar level.

1. Regular follow-up

   Regular follow-ups are arranged for a patient to monitor his /her conditions and symptoms of recurrence. Should there be any new symptom, the doctor must be notified as soon as possible.

2. Palliative treatment and caring for other symptoms

   Such as maintain nutrition and pain killing, etc.

• Regeneration Society Ltd
• Cancerinformation.com.hk
• Hong Kong Cancer Fund
• Hong Kong Cancer Registry
• The Hong Kong Anti-Cancer Society
• The Hong Kong Society for Rehabilitation

1. Introduction

   Pancreas and the biliary tract are important organs inside our body. The pancreas secretes digestive enzymes that are collected by the pancreatic ducts. The bile ducts transport bile synthesized in the liver to the small intestine. The common bile duct and the pancreatic duct merge with each other before entering the duodenum in one single channel.

   Diseases of the pancreas and bile ducts in general cannot be diagnosed accurately by means of external examination. Using endoscopic retrograde cholangio-pancreatography, endoscopists can cannulate the pancreatic duct or the bile duct through the opening in the duodenum and perform X-ray imaging. The procedure allows accurate diagnosis of biliary obstruction (e.g. due to gallstone or tumour), acute cholangitis, acute or chronic pancreatitis and post operative biliary or pancreatic ductal leakage. The endoscopists can also perform therapeutic procedures using various accessory tools.

2. Preparation before the procedure

   • Patients need to be fasted for at least 6 hours before the procedure.
   • Emergency procedure may be performed in seriously ill patients.
   • Patients should inform the medical staff of any major medical problems including diabetes, hypertension and valvular heart disease, and continue their medications as instructed.
   • Patients should also provide information regarding their current medications especially antiplatelet and anticoagulation drugs and history of drug allergy.

3. The procedure

   • Prior to the examination, intravenous sedative will be given to the patient to reduce any anxiety or discomfort that may arise from the procedure. Local anaesthetic will also be applied to throat of the patient. A flexible endoscope with a diameter of 1.3 –1.4 cm will then be passed by the endoscopist through the mouth into the duodenum.
   • During the procedure, consciousness is maintained though patients may feel drowsy.
   • Generally speaking, the procedure may last for 15-60 minutes depending on individual cases. In complicated cases that require additional therapies, the examination time may be prolonged.
   • Patients' co-operation with medical staff will help shorten the examination time.

4. After the procedure

   Patients should resume oral intake only after the effect of anaesthetic or sedative has worn off. If naso-biliary drainage is needed, the patient should carefully maintain the position of the tube as dislodgement of the tube from the bile duct will result in failure of treatment.

5. Risk and complication

   • Minor discomfort including nausea and feeling of abdominal distension is common.
   • The local anaesthetic causes numbness in the throat for around an hour, resulting in difficulty in swallowing.
   • Major complications including perforation, bleeding, cardiopulmonary events, acute cholangitis, pancreatitis and so on may happen but in general, the risk is less than 10%.
   • Should major complications occur, emergency surgical treatment may be needed. Death may occur as a result of the serious complications. The risk of complication may differ between different patients and the therapeutic procedures performed. Patients should consult the attending physicians for the detail of the endoscopic procedures.

6. Follow up

   • Patients can contact the endoscopy unit for any discomfort after the procedure, or if the patients have any question about the examination result and drug treatment.
   • However, if serious events develop, such as passage of large amount of blood, severe abdominal pain, fever, etc. patients should seek medical advice at the nearest Accident and Emergency Department.

7. Remarks

   For further information please contact your doctor.

1. Introduction

   Percutaneous Transhepatic Cholangiogram assists in obtaining diagnostic information for suspected bile duct disease and providing temporary or permanent drainage of bile of there is biliary tree blockage.

2. Preparation before the procedure

   • A written consent is required.
   • Fast for 4-6 hours before examination.
   • Please inform medical staff before the procedure if the patient suspects or already pregnant.
   • The bleeding parameters will be checked before the procedure. The doctor will try to correct if necessary.
   • Doctors will prescribe antibiotic according to patient condition, steroid will be given for patients with a history of allergy
   • Venous access will be prepared.

3. The procedure

   • Patient will be given sedation before the procedure.
   • Patient is kept in face-up position, and the doctor will perform local anesthesia on patient’s upper abdomen.
   • The procedure involves puncturing a branch of the bile duct using a thin needle, often under ultrasound or fluoroscopic guidance.
   • Contrast medium is then injected to opacify the biliary tree under fluoroscopy.
   • If there is blockage of biliary tree, biliary drainage is performed.
   • A drainage catheter will be placed in the biliary tree using various exchange catheters and guide wires. The drainage catheter will then be connected to a drainage bag for external bile drainage. If the obstruction can be negotiated through, the drainage catheter is placed with its distal end in the duodenum for both external and internal drainage.
   • The procedure may take one or two hours to perform.

4. After the procedure

   After the procedure, patient will be observed in the ward. He / she should inform the medical staff as soon as possible in case of any problem.

5. Risk and complication

   This procedure has certain risk, acute major complications such as haemobilia, septicaemia and bile peritonitis occur in 4-6% of patients. The possibility of death is about 0.5-5.6%.

6. Remarks

   For further information please contact your doctor.