What is pancreatic cancer?

Pancreatic cancer is what doctors call malignant tumors that form in the pancreas. Pancreatic carcinoma is initially limited to the pancreas, but usually grows quickly and forms metastases (daughter ulcers) early on, which settle in other organs.

Pancreatic cancer is particularly aggressive and is usually only discovered at an advanced stage: Only ten percent of the affected women and nine percent of the male patients survive the first five years after diagnosis, according to the cancer registry of the Robert Koch Institute.

Pancreatic cancer is relatively rare ; only three percent of all malignant tumors in adulthood are pancreatic carcinomas. 17,000 people develop it in Germany every year, reports the Robert Koch Foundation.

Pancreatic cancer usually only occurs at an advanced age, from the age of 60. On average, men develop it at 70 and women at 75. In individual cases, however, significantly younger people can also be affected.

Anatomy and functions of the pancreas

The pancreas lies across the upper abdomen, between the stomach, liver and spleen and in front of the spine. It is only about 15 centimeters tall, weighs around 100 grams and consists of three sections: a thick section, which medical professionals refer to as the head, a central section, and a thin tail.

The small organ has two important tasks : it produces the hormones insulin and glucagon, which regulate blood sugar levels, and it produces more than 20 different digestive enzymes, which break down food in the intestines into tiny components. Only in this way can energy-producing substances and nutrients be absorbed into the bloodstream.

Pancreatic Cancer: Exocrine Tumors

The pancreas has a special glandular tissue for both tasks: the exocrine tissue (it forms the main part of the organ), which produces the digestive juices, and the endocrine tissue, which produces the hormones. Cancer can develop in both types of tissue, so doctors speak of exocrine pancreatic carcinoma or endocrine pancreatic carcinoma.

95 percent of malignant tumors form in the exocrine part of the pancreas. The cancer usually develops in the exocrine tissue of the head of the pancreas.

Endocrine tumors: insulinoma, gastrinoma and glucagonoma

Malignant tumors rarely develop in the endocrine area of ​​the pancreas - they only make up five percent of all pancreatic carcinomas and are known as insulinomas, gastrinomas or glucagonomas, depending on the type of cell.

The insulinoma: is the most common endocrine pancreatic tumor, but it is benign in 90 percent of all cases. This tumor causes the hormone insulin to be produced in an uncontrolled manner. This causes the blood sugar level to drop and the person concerned suffers from low blood sugar (hypoglycaemia).

The gastrinoma: This tumor produces large amounts of the hormone gastrin. The messenger substance causes the stomach to secrete more stomach acid and digestive enzymes. More than half of all gastrinomas are malignant.

The glucagonoma : The tumor triggers an increased production of the hormone glucagon, which increases the blood sugar level. Most of the glucagonomas are malignant. However, they grow only slowly and are very rare: Overall, glucagonomas only make up about one percent of all pancreatic tumors.

Pancreatic cancer: symptoms

Pancreatic cancer causes little or no symptoms for a long time . Symptoms can only be felt at an advanced stage, when it is already pressing on nerves or has affected other organs, which is why pancreatic cancer is often diagnosed late.

In addition, the symptom of pancreatic cancer are often uncharacteristic (doctors speak of unspecific symptoms) and also point to many other diseases.

Nonspecific symptoms in pancreatic cancer

The following unspecific symptoms can indicate pancreatic cancer:

Abdominal and back pain : 80 percent of pancreatic cancer patients have upper abdominal pain and / or back pain. Abdominal pain occurs when the tumor grows and presses on the surrounding nerves. The stomach ache often radiates to the back. They can also occur at night.

Because the pancreas is located directly in front of the spine (the head of the pancreas is at the level of the second and third lumbar vertebrae) and a tumor can press or irritate the nerves there, it often causes back pain. They can radiate in a ring up to the belly.

Often, patients who have persistent back pain are sent to the orthopedic surgeon first to treat the symptoms. This means that valuable time is lost for the correct therapy in the case of pancreatic cancer. If a patient has other complaints in addition to back pain, such as digestive problems and weight loss, the pancreas should definitely be taken into account during the examination.

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Indigestion and weight loss : If the tumor affects digestion, nausea, vomiting , gas, or foul-smelling diarrhea may be signs of pancreatic cancer. In addition, patients often lose weight significantly within a few months.

The reason for the unintentional weight loss is that the pancreas does not produce enough digestive enzymes due to the tumor and the digestion of food no longer works properly. 90 percent of all pancreatic cancer patients show significant weight loss at the time of diagnosis.

Blood clots and bleeding disorders: If the tumor presses on surrounding blood vessels, blood clots can form and block a vessel.

Since the pancreas also produces a high concentration of the blood clotting factor thrombokinase, the tumor infestation can disrupt blood clotting. Wounds heal more slowly and dangerous internal bleeding is possible.

Feeling of weakness: Due to the tumor disease, those affected feel less productive, exhausted, weak.

Specific symptoms in pancreatic cancer

In the later course of the disease, specific symptoms indicate the tumor:

• Fatty stool: The changed stool occurs when the carcinoma presses on the bile duct, constricts it and the bile can no longer drain. As a result, the bile fluid in the intestine is missing and the digestion of fat there is impaired: the stool is light, smeary or shiny and smells very unpleasant, pungent (doctors call this fat stool).
• Jaundice: When the bile builds up, the yellow pigment contained in the bile is increasingly released into the blood and is deposited in other areas of the body. The skin and the white skin of the eyes turn yellow, the urine has a dark, brown color. Itching can also occur.
• Inflammation and Diabetes: Also inflammation of the pancreas (pancreatitis) or aType 2 diabetes that suddenly worsens or appears for the first time for inexplicable reasons indicates a possible cancer.

Symptoms of endocrine pancreatic tumors

The oncologist recognizes the rare tumors of the hormone-producing tissue in the pancreas by specific symptoms that often arise from the impaired hormone production.

With insulinoma, patients suffer from sweating, tremors , cravings, feelings of weakness, lightheadedness or paleness, all caused by low blood sugar levels.

Overproduction of gastrin in gastrinoma can lead to a stomach ulcer , diarrhea, severe abdominal pain and internal bleeding.

A typical symptom of a glucagonoma that has too much sugar in the patient's blood is a scaly, red-brown rash that first appears on the groin and then spreads to the buttocks, forearms, and legs. Those affected often have a shiny orange tongue and cracked corners of the mouth.

 

Pancreatic cancer: causes

The cause of pancreatic cancer are still not fully understood, but various factors are known that increase the risk of developing pancreatic cancer. Many of them have to do with lifestyle.

Lifestyle : The biggest risk factor is smoking: Smokers are 3.5 times more likely to get pancreatic cancer than non-smokers. Studies show that around a third of all pancreatic cancers are caused by smoking.

You don't even have to pick up a cigarette yourself, passive smoking also increases the risk of cancer. Very overweight (BMI> 30), frequent alcohol consumption, high-fat, processed meat products and smoked or grilled dishes could also promote pancreatic cancer.

Psychological causes : To what extent negative psychological stress can increase the risk of cancer, British researchers from the Department of Epidemology and Public Health at University College London examined in a large meta-study in 2017. They analyzed the data of more than 160,000 people between the ages of 16 and 107 years. The subjects had no diagnosed cancer at the start of the study.

For ten years, they were examined once a year, asked about their state of health and lifestyle, such as alcohol and cigarette consumption, physical activity and diet, and stressful psychological stress.

The result: The study participants who suffered from severe stress, had a 32 percent higher risk of dying from cancer. In particular, the risk of blood cancer ( leukemia ) increased due to prolonged stress, followed by pancreatic cancer, esophageal cancer and colon cancer , the study showed.

Chemicals : There are some chemicals that may promote pancreatic cancer. Usually, however, you only come into contact with them through accidents in the workplace or when safety regulations are violated.

Other diseases : In addition, chronic inflammation of the pancreas (pancreatitis) promotes the development of a tumor. Those who suffer from type 2 diabetes also have an increased risk of cancer.

If diabetes inexplicably worsens or appears for the first time, pancreatic cancer may be the cause. If cysts develop in the pancreas, they are usually precursors to carcinoma.

Is Pancreatic Cancer Hereditary? : There is also a genetic risk for pancreatic cancer. If more than two first-degree relatives (parents, siblings, children) developed pancreatic cancer, there may be familial pancreatic cancer (FPC) in which risk genes are inherited. Relatives then have an 18 percent higher risk of developing pancreatic cancer as well.

Even if a family has multiple cases of various cancers, such as colon, breast, ovarian, or skin cancer , people can be more prone to developing a pancreatic tumor. Families with both pancreatic cancer and black skin cancer (malignant melanoma) may have what is known as multiple birthmark and melanoma-pancreatic cancer syndrome - triggered by a genetic change that favors both types of cancer.

Some rare hereditary diseases (for example Peutz-Jeghers syndrome) also promote cancer development in the pancreas. People who suffer from hereditary inflammation of the pancreas (pancreatitis) are at a significantly higher risk of pancreatic cancer.

In up to 40 percent of all case,those affected develop pancreatic cancer.

Pancreatic cancer: diagnosis

If the symptoms described occur, you should immediately consult a general practitioner or gastroenterologist (specialist in digestive diseases) to have them clarified. You can also contact the outpatient department of a specialized hospital.

Often a more harmless disease is the cause, but if pancreatic cancer is the reason, the same applies as with any cancer: the earlier a tumor is discovered, the greater the chances that it has not yet spread and that the treatment will be successful.

The doctor will perform the following tests to make a diagnosis:

Medical history and physical examination

During the examination, the attending physician first asks what symptoms the patient has and what his general condition is. He then does a physical exam and palpates the abdomen to determine if there is any hardening in the abdomen.

Pancreatic cancer: blood tests

To make the diagnosis, some blood tests are also carried out (blood count) and checked for changes in blood proteins, an increased amount of liver and pancreatic enzymes and an increased blood count (this measures the rate at which certain components of the blood decrease). All of these can indicate a tumor.
Elevated liver values ​​may indicate that the lump is narrowing the bile duct and preventing the bile from draining into the small intestine.

Tumor markers

Another indication of cancer are so-called tumor markers . These are special substances that are increasingly produced in the body in a malignant tumor and can be detected in the blood. A well-known tumor marker in pancreatic cancer is the so-called carbohydrate antigen 19-9, or CA 19-9 for short. It is a glycoprotein that is excreted in the bile.

However, these markers do not provide a clear diagnosis because, on the one hand, they can also be increased in other diseases, such as inflammation of the pancreas or the gallbladder, on the other hand, there are also patients who have pancreatic cancer and in whom the value is still not increased. A tumor marker is therefore only additional evidence of cancer and cannot replace other examination methods.

The CA-19-9 values ​​are primarily used to control the course of therapy in order to check the success of the treatment.

Imaging procedures

If there is suspicion of pancreatic cancer, doctors need to determine exactly where the tumor is. About 70 percent of pancreatic carcinomas are located in the head of the pancreas, 20 percent in the body of the organ and 10 percent in the tail.

In addition, doctors need to find out how far the tumor has progressed in order to make a decision about the right therapy. Are the lymph nodes already affected? Has the tumor metastasized? A pancreatic carcinoma can already form metastases from a size of one centimeter, most often they develop in the liver, lungs and bones.

But they can also arise in other organs. To clarify this, doctors can use various imaging methods such as ultrasound , endosonography , endoscopic retrograde cholangiopancratography (ERCP), computered tomography (CT), magnetic resonance imaging ( MRI ) and x-rays .

Ultrasound: An ultrasound examination (sonography) is usually the first step. With the help of sonography, the doctor can clarify unclear upper abdominal complaints and take a close look at the condition of the pancreas, especially the pancreatic head area, and often recognize a tumor. It can also be used to determine whether a tumor has narrowed the bile duct and caused bile congestion that needs to be cleared quickly.

Endosonography: Since the pancreas, due to its particular location (it is deep inside the body, behinds the stomach, the head of the pancreas is in the curvature of the duodenum) and possible air layers, cannot always be clearly seen on the ultrasound image, an ultrasound examination can also be performed inside the body (so-called endosonography) may be necessary.

The doctor pushes a thin tube with an ultrasound probe at the tip through the esophagus and stomach into the duodenum and uses the ultrasound probe to obtain images of the digestive tract. Since the pancreas is in close proximity, even the smallest noticeable changes in tissue can be seen there. On the ultrasound, the doctor can also often see whether the tumor has already infected neighboring tissue or organs in the vicinity.

He can also perform an endoscopic retrograde cholangio-pancreatography (ERCP) mirroring of the biliary and pancreatic ducts.

During the examination, the patient has to swallow a thin tube on an empty stomach. The gag stimulus can usually be suppressed well with an anesthetic spray in the mouth and throat. Patients who are afraid of this examination method can also receive a light anesthetic. The examination usually takes less than an hour in total.

CT and MRI: To determine whether the tumor has already attacked other organs, whether lymph nodes are affected and whether it has metastasized in other areas of the body (so-called distant metastases), the doctor can also do a computed tomography (CT) or magnetic resonance tomography (MRI) scan. carry out.

MRI is often combined with what is known as magnetic resonance cholangio-pancreatic imaging (MRCP), which specifically depicts the fluid-filled bile duct and the excretory duct of the pancreas in detail.

Lung metastases can also be found on an X-ray .

biopsy

In order to determine whether the tissue change in the pancreas is actually a malignant tumor, the doctor can, for example, insert a fine hollow needle into the body during the endosonographic examination and take a tissue sample from the tumor (biopsy).

A pathologist then examines the tissue of the cell material (histologically) under a microscope. Based on the appearance and arrangement of the cells, he can judge whether the tumor is benign or malignant and from which tissue part of the pancreas it originates.

"Trial" operation

If a diagnosis with these methods is ambiguous, a laparoscopic operation may also be advisable, in which only a tiny incision is made, through which the doctor inserts an optical device. The doctor examines the abdomen with a camera. If a tumor is discovered, the surgeon can surgically remove it in certain cases. However, if the cancer has spread to the peritoneum and other organs, doctors will consider other therapies.

Staging - determine the stage of the disease

Once all the examinations have been carried out and the results are available, the doctor makes the final diagnosis. In order to precisely describe the stage of the disease and to select the best therapy for the patient, medical professionals use an internationally standardized TNM system:
T stands for the original tumor (also called primary tumor), N (node) stands for lymph nodes, M stands for metastases.

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