Pancreatic Cancer, Exocrine

Definition

Exocrine pancreatic cancer is a disease in which cancerous cells originate within the tissues of the pancreas that produce digestive juices.

Description

The pancreas is a 6-8 in (15-20 cm) long, slipper-shaped gland located in the abdomen. It lies behind the stomach, within a loop formed by the small intestine. Other nearby organs include the gallbladder, spleen, and liver. The pancreas has a wide end (head), a narrow end (tail), and a middle section (body). A healthy pancreas is important for normal food digestion and also plays a critical role in the body's metabolic processes. The pancreas has two main functions, and each are performed by distinct types of tissue. The exocrine tissue makes up the vast majority of the gland and secretes fluids into the other organs of the digestive system. The endocrine tissue secretes hormones (like insulin) that are circulated in the bloodstream, and these substances control how the body stores and uses nutrients. The exocrine tissue of the pancreas, comprised mostly of acinar cells and ductal cells, produces pancreatic (digestive) juices. These juices contain several enzymes that help break down proteins and fatty foods. The exocrine pancreas forms an intricate system of channels or ducts, which are tubular structures that carry pancreatic juices to the small intestine where they are used for digestion.

Pancreatic tumors are classified as either exocrine or endocrine tumors depending on which type of tissue they arise from within the gland. Ninety-five percent of pancreatic cancers occur in the tissues of the exocrine pancreas. Ductal adenocarcinomas arise in the cells that line the ducts of the exocrine pancreas and account for 80% to 90% of all tumors of the pancreas. Unless specified, nearly all reports on pancreatic cancer refer to ductal adenocarcinomas. Less common types of pancreatic exocrine tumors include acinar cell carcinoma, cystic tumors that are typically benign but may become cancerous, and papillary tumors that grow within the pancreatic ducts. Pancreatoblastoma is a very rare disease that primarily affects young children. Two-thirds of pancreatic tumors occur in the head of the pancreas, and tumor growth in this area can lead to the obstruction of the nearby common bile duct that empties bile fluid into the small intestine. When bile cannot be passed into the intestine, patients may develop yellowing of the skin and eyes (jaundice) due to the buildup of bilirubin (a component of bile) in the bloodstream. Tumor blockage of bile or pancreatic ducts may also cause digestive problems since these fluids contain critical enzymes in the digestive process. Depending on their size, pancreatic tumors may cause abdominal pain by pressing on the surrounding nerves. Because of its location deep within the abdomen, pancreatic cancer often remains undetected until it has spread to other organs such as the liver or lung. Pancreatic cancer tends to rapidly spread to other organs, even when the primary (original) tumor is relatively small.

Though pancreatic cancer accounts for only 3% of all cancers, it is the fifth most frequent cause of cancer deaths. In 2001, an estimated 29,200 new cases of pancreatic cancer will be diagnosed in the United States. Pancreatic cancer is primarily a disease associated with advanced age, with 80% of cases occurring between the ages of 60 and 80. Men are almost twice as likely to develop this disease than women. Countries with the highest frequencies of pancreatic cancer include the United States, New Zealand, Western European nations, and Scandinavia. The lowest occurrences of the disease are reported in India, Kuwait and Singapore. African Americans have the highest incidence of pancreatic cancer of any ethnic group worldwide. Whether this difference is due to diet or environmental factors remains unclear.

Causes and symptoms

Although the exact cause for pancreatic cancer is not known, several risk factors have been shown to increase susceptibility to this particular cancer, the greatest of which is cigarette smoking. Approximately one-third of pancreatic cancer cases occur among smokers. People who have diabetes develop pancreatic cancer twice as often as non-diabetics. Numerous studies suggest that a family history of pancreatic cancer is another strong risk factor for developing the disease, particularly if two or more relatives in the immediate family have the disease. Other risk factors include chronic (long-term) inflammation of the pancreas (pancreatitis), diets high in fat, and occupational exposure to certain chemicals such as petroleum.

Pancreatic cancer often does not produce symptoms until it reaches an advanced stage. Patients may then present with the following signs and symptoms:

• upper abdominal and/or back pain
• jaundice
• weight loss
• loss of appetite
• diarrhea
• weakness
• nausea

These symptoms may also be caused by other illnesses; therefore, it is important to consult a doctor for an accurate diagnosis.

Diagnosis

Pancreatic cancer is difficult to diagnose, especially in the absence of symptoms, and there is no current screening method for early detection. The most sophisticated techniques available often do not detect very small tumors that are localized (have not begun to spread). At advanced stages where patients show symptoms, a number of tests may be performed to confirm diagnosis and to assess the stage of the disease. Approximately half of all pancreatic cancers are metastatic (have spread to other sites) at the time of diagnosis.

The first step in diagnosing pancreatic cancer is a thorough medical history and complete physical examination. The abdomen will be palpated to check for fluid accumulation, lumps, or masses. If there are signs of jaundice, blood tests will be performed to rule out the possibility of liver diseases such as hepatitis. Urine and stool tests may be performed as well.

Non-invasive imaging tools such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be used to produce detailed pictures of the internal organs. CT is the tool most often used to diagnose pancreatic cancer, as it allows the doctor to determine if the tumor can be removed by surgery or not. It is also useful in staging a tumor by showing the extent to which the tumor has spread. During a CT scan, patients receive an intravenous injection of a contrast dye so the organs can be visualized more clearly. MRI may be performed instead of CT if a patient has an allergy to the CT contrast dye. In some cases where the tumor is impinging on blood vessels or nearby ducts, MRI may be used to generate an image of the pancreatic ducts.

If the doctor suspects pancreatic cancer and no visible masses are seen with a CT scan, a patient may undergo a combination of invasive tests to confirm the presence of a pancreatic tumor. Endoscopic ultrasound (EUS) involves the use of an ultrasound probe at the end of a long, flexible tube that is passed down the patient's throat and into the stomach. This instrument can detect a tumor mass through high frequency sound waves and echoes. EUS can be accompanied by fine needle aspiration (FNA), where a long needle, guided by the ultrasound, is inserted into the tumor mass in order to take a biopsy sample. Endoscopic retrograde cholangiopancreatography (ERCP) is a technique often used in patients with severe jaundice because it enables the doctor to relieve blockage of the pancreatic ducts. The doctor, guided by endoscopy and x rays, inserts a small metal or plastic stent into the duct to keep it open. During ERCP, a biopsy can be done by collecting cells from the pancreas with a small brush. The cells are then examined under the microscope by a pathologist, who determines the presence of any cancerous cells.

In some cases, a biopsy may be performed during a type of surgery called laparoscopy, which is done under general anesthesia. Doctors insert a small camera and instruments into the abdomen after a minor incision is made. Tissue samples are removed for examination under the microscope. This procedure allows a doctor to determine the extent to which the disease has spread and decide if the tumor can be removed by further surgery.

An angiography is a type of test that studies the blood vessels in and around the pancreas. This test may be done before surgery so that the doctor can determine the extent to which the tumor invades and interacts with the blood vessels within the pancreas. The test requires local anesthesia and a catheter is inserted into the patient's upper thigh. A dye is then injected into blood vessels that lead into the pancreas, and x rays are taken.

As of April 2001, doctors at major cancer research institutions such as Memorial Sloan-Kettering Cancer Center in New York are investigating CT angiography, an imaging technique that is less invasive than angiography alone. CT angiography is similar to a standard CT scan, but allows doctors to take a series of pictures of the blood vessels that support tumor growth. A dye is injected as in a CT scan (but at rapid intervals) and no catheter or sedation is required. A computer generates 3D images from the pictures that are taken, and the information is gathered by the surgical team who will develop an appropriate strategy if the patient's disease can be operated on.

Treatment

Staging

After cancer of the pancreas has been diagnosed, doctors typically use a TNM staging system to classify the tumor based on its size and the degree to which it has spread to other areas in the body. T indicates the size and local advancement of the primary tumor. Since cancers often invade the lymphatic system before spreading to other organs, regional lymph node involvement (N) is an important factor in staging. M indicates whether the tumor has metastasized (spread) to distant organs. In stage I, the tumor is localized to the pancreas and has not spread to surrounding lymph nodes or other organs. Stage II pancreatic cancer has spread to nearby organs such as the small intestine or bile duct, but not the surrounding lymph nodes. Stage III indicates lymph node involvement, whether the cancer has spread to nearby organs or not. Stage IVA pancreatic cancer has spread to organs near the pancreas such as the stomach, spleen, or colon. Stage IVB is a cancer that has spread to distant sites (liver, lung). If pancreatic cancer has been treated with success and then appears again in the pancreas or in other organs, it is referred to as recurrent disease.

Treatment of pancreatic cancer will depend on several factors, including the stage of the disease and the patient's age and overall health status. A combination of therapies is often employed in the treatment of this disease to improve the patient's chances for survival. Surgery is used whenever possible and is the only means by which cancer of the pancreas can be cured. However, less than 15% of pancreatic tumors can be removed by surgery. By the time the disease is diagnosed (usually at stage III), therapies such as radiation and chemotherapy or both are used in addition to surgery to relieve a patient's symptoms and enhance quality of life. For patients with metastatic disease, chemotherapy and radiation are used mainly as palliative (pain alleviating) treatments.

Surgery

Three types of surgery are used in the treatment of pancreatic cancer, depending on what section of the pancreas the tumor is located in. A Whipple procedure removes the head of the pancreas, part of the small intestine and some of the surrounding tissues. This procedure is most common since the majority of pancreatic cancers occur in the head of the organ. A total pancreatectomy removes the entire pancreas and the organs around it. Distal pancreatectomy removes only the body and tail of the pancreas. Chemotherapy and radiation may precede surgery (neoadjuvant therapy) or follow surgery (adjuvant therapy). Surgery is also used to relieve symptoms of pancreatic cancer by draining fluids or bypassing obstructions. Side effects from surgery can include pain, weakness, fatigue, and digestive problems. Some patients may develop diabetes or malabsorption as a result of partial or total removal of the pancreas.

Radiation therapy

Radiation therapy is sometimes used to shrink a tumor before surgery or to remove remaining cancer cells after surgery. Radiation may also be used to relieve pain or digestive problems caused by the tumor if it cannot be removed by surgery. External radiation therapy refers to radiation applied externally to the abdomen using a beam of high-energy x rays. High-dose intraoperative radiation therapy is sometimes used during surgery on tumors that have spread to nearby organs. Internal radiation therapy refers to the use of small radioactive seeds implanted in the tumor tissue. The seeds emit radiation over a period of time to kill tumor cells. Radiation treatment may cause side effects such as fatigue, tender or itchy skin, nausea, vomiting, and digestive problems.

Chemotherapy

Chemotherapeutic agents are powerful drugs that are used to kill cancer cells. They are classified according to the mechanism by which they induce cancer cell death. Multiple agents are often used to increase the chances of tumor cell death. Gemcitabine is the standard drug used to treat pancreatic cancers and can be used alone or in combination with other drugs, such as 5-flourouracil (5-FU). Other drugs are being tested in combination with gemcitabine in several ongoing clinical trials, specifically irinotecan (CPT-11) and oxaliplatin. Chemotherapy may be administered orally or intravenously in a series of doses over several weeks. During treatment, patients may experience fatigue, nausea, vomiting, hair loss, and mouth sores, depending on which drugs are used.

Biological treatments

Numerous vaccine treatments are being developed in an effort to stimulate the body's immune system into attacking cancer cells. This is also referred to as immunotherapy. Another type of biological treatment involves using a targeted monoclonal antibody to inhibit the growth of cancer cells. The antibody is thought to bind to and neutralize a protein that contributes to the growth of the cancer cells. Investigational treatments such as these may be considered by patients with metastatic disease who would like to participate in a clinical trial. Biological treatments typically cause flu-like symptoms (chills, fever, loss of appetite) during the treatment period.

Alternative treatment

Acupuncture or hypnotherapy may be used in addition to standard therapies to help relieve the pain associated with pancreatic cancer. Because of the poor prognosis associated with pancreatic cancer, some patients may try special diets with vitamin supplements, certain exercise programs, or unconventional treatments not yet approved by the FDA. Patients should always inform their doctors of any alternative treatments they are using as they could interfere with standard therapies. As of the year 2000, the National Cancer Institute (NCI) is funding phase III clinical trials of a controversial treatment for pancreatic cancer that involves the use of supplemental pancreatic enzymes (to digest cancerous cells) and coffee enemas (to stimulate the liver to detoxify the cancer). These theories remain unproven and the study is widely criticized in the medical community. It remains to been seen whether this method of treatment has any advantage over the standard chemotherapeutic regimen in prolonging patient survival or improving quality of life.

Prognosis

Unfortunately, cancer of the pancreas is often fatal, and median survival from diagnosis is less than six months, while the five-year survival rate is 4%. This is mainly due to the lack of screening methods available for early detection of the disease. Yet, even when localized tumors can be removed by surgery, patient survival after five years is only 10% to 15%. These statistics demonstrate the aggressive nature of most pancreatic cancers and their tendency to recur. Pancreatic cancers tend to be resistant to radiation and chemotherapy and these modes of treatment are mainly used to relieve pain and tumor burden.

Prevention

Although the exact cause of pancreatic cancer is not known, there are certain risk factors that may increase a person's chances of developing the disease. Quitting smoking will certainly reduce the risk for pancreatic cancer and many other cancers. The American Cancer Society recommends a diet rich in fruits, vegetables, and dietary fiber in order to reduce the risk of pancreatic cancer. According to the NCI, workers who are exposed to petroleum and other chemicals may be at greater risk for developing the disease and should follow their employer's safety precautions. People with a family history of pancreatic cancer are at greater risk than the general population, as a small percentage of pancreatic cancers are considered hereditary.

KEY TERMS

Acinar cell carcinoma— A malignant tumor arising from the acinar cells of the pancreas.

Angiography— Diagnostic technique used to study blood vessels in a tumor.

Biopsy— Removal and microscopic examination of cells to determine whether they are cancerous.

Cancer vaccines— A treatment that uses the patient's immune system to attack cancer cells.

Chemotherapy— Drug treatment administered to kill cancerous cells.

Ductal adenocarcinoma— A malignant tumor arising from the duct cells within a gland.

Endoscopic retrograde cholangiopancreatography (ERCP)— Diagnostic technique used to obtain a biopsy. Also a surgical method of relieving biliary obstruction caused by a tumor.

Endoscopic ultrasonography (EUS)— Diagnostic imaging technique in which an ultrasound probe is inserted down a patient's throat to determine if a tumor is present.

Exocrine— Refers to glands which secrete their products through a duct.

Laparoscopic surgery— Minimally invasive surgery in which a camera and surgical instruments are inserted through a small incision.

Pancreatectomy— Partial or total surgical removal of the pancreas.

Radiation therapy— Use of radioisotopes to kill tumor cells. Applied externally through a beam of x rays, intraoperatively (during surgery), or deposited internally by implanting radioactive seeds in tumor tissue.

Whipple procedure— Surgical removal of the head of the pancreas, part of the small intestine, and some surrounding tissue.

Resources

BOOKS

Teeley, Peter, and Philip Bashe. The Complete Cancer Survival Guide. New York: Doubleday, 2000.

PERIODICALS

Bornman, P. C., and I. J. Beckingham. "ABC of Diseases of Liver, Pancreas, and Biliary System. Pancreatic Tumours." British Medical Journal 322, no. 7288 (24 March 2001): 721-3.

Haut, E., A. Abbas, and A. Schuricht. "Pancreatic Cancer: The Role of the Primary Care Physican." Consultant 39, no. 12 (December 1999): 3329.

Parks, R. W., and O. J. Garden. "Ensuring Early Diagnosis in Pancreatic Cancer." Practitioner 244, no. 1609 (April 2000): 336-8, 340-1, 343.

ORGANIZATIONS

CancerNet. National Cancer Institute, 9000 Rockville Pike, Bldg. 31, Rm.10A16, Bethesda, Maryland, 20892. (800) 422-6237. 〈http://wwwicic.nci.nih.gov〉.

Hirshberg Foundation for Pancreatic Cancer Research. 375 Homewood Rd., Los Angeles, CA 90049. (310) 472-6310. 〈http://www.pancreatic.org〉.

National Pancreas Foundation. PO Box 935, Wexford, PA 15090-0935. 〈http://www.pancreasfoundation.org〉.

Pancreatic Cancer Action Network. PO Box 1010, Torrance, CA 90505. (877) 272-6226. 〈http://www.pancan.org〉.

OTHER

Johns Hopkins Medical Institutions. July 20, 2001 〈http://www.path.jhu.edu/pancreas〉.

Memorial Sloan-Kettering Cancer Center. Patient Information on Pancreatic Cancer. July 20, 2001. 〈http://www.mskcc.org/patients_n_public/about_cancer_and_treatment/cancer_information_by_type/pancreatic_cancer/index.html〉.

University of Texas MD Anderson Cancer Center. Pancreatic Tumor Study Group. July 20, 2001. 〈http://www.mdanderson.org/DEPARTMENTS/pancreatic/〉.

"What You Need To Know About Cancer of the Pancreas." National Cancer Institute. December 12, 2000. [cited July 20, 2001]. 〈http://cancernet.nci.nih.gov/wyntk_pubs/pancreas.htm〉.

Pancreatic cancer, exocrine

Definition

Exocrine pancreatic cancer is a disease in which cancerous cells originate within the tissues of the pancreas that produce digestive juices.

Description

The pancreas is a six-to eight-inch long, slipper-shaped gland located in the abdomen. It lies behind the stomach, within a loop formed by the small intestine. Other nearby organs include the gallbladder, spleen, and liver. The pancreas has a wide end (head), a narrow end (tail) and a middle section (body). A healthy pancreas is important for normal food digestion and also plays a critical role in the body's metabolic processes. The pancreas has two main functions, and each are performed by distinct types of tissue. The exocrine tissue makes up the vast majority of the gland and secretes fluids into the other organs of the digestive system. The endocrine tissue secretes hormones (like insulin) that are circulated in the bloodstream, and these substances control how the body stores and uses nutrients. The exocrine tissue of the pancreas produces pancreatic (digestive) juices. These juices contain several enzymes that help break down proteins and fatty foods. The exocrine pancreas forms an intricate system of channels or ducts, which are tubular structures that carry pancreatic juices to the small intestine where they are used for digestion.

Pancreatic tumors are classified as either exocrine or endocrine tumors depending on which type of tissue they arise from within the gland. Ninety-five percent of pancreatic cancers occur in the tissues of the exocrine pancreas. Ductal adenocarcinomas arise in the cells that line the ducts of the exocrine pancreas and account for 80% to 90% of all tumors of the pancreas. Unless specified, nearly all reports on pancreatic cancer refer to ductal adenocarcinomas. Less common types of pancreatic exocrine tumors include acinar cell carcinoma , cystic tumors that are typically benign but may become cancerous, and papillary tumors that grow within the pancreatic ducts. Pancreatoblastoma is a very rare disease that primarily affects young children. Two-thirds of pancreatic tumors occur in the head of the pancreas, and tumor growth in this area can lead to the obstruction of the nearby common bile duct that empties bile fluid into the small intestine. When bile cannot be passed into the intestine, patients may develop yellowing of the skin and eyes (jaundice) due to the buildup of bilirubin (a component of bile) in the bloodstream. Tumor blockage of bile or pancreatic ducts may also cause digestive problems since these fluids contain critical enzymes in the digestive process. Depending on their size, pancreatic tumors may cause abdominal pain by pressing on the surrounding nerves. Because of its location deep within the abdomen, pancreatic cancer often remains undetected until it has spread to other organs such as the liver or lung. Pancreatic cancer tends to rapidly spread to other organs, even when the primary (original) tumor is relatively small.

Demographics

Though pancreatic cancer accounts for only 3% of all cancers, it is the fifth most frequent cause of cancer deaths. In 2001, an estimated 29, 200 new cases of pancreatic cancer will be diagnosed in the United States. Pancreatic cancer is primarily a disease associated with advanced age, with 80% of cases occurring between the ages of 60 and 80. Men are almost twice as likely to develop this disease than women. Countries with the highest frequencies of pancreatic cancer include the U.S., New Zealand, Western European nations, and Scandinavia. The lowest occurrences of the disease are reported in India, Kuwait and Singapore. African-Americans have the highest rate of pancreatic cancer of any ethnic group worldwide. Whether this difference is due to diet or environmental factors remains unclear.

Causes and symptoms

Although the exact cause for pancreatic cancer is not known, several risk factors have been shown to increase susceptibility to this particular cancer, the greatest of which is cigarette smoking. Approximately one-third of pancreatic cancer cases occur among smokers. People who have diabetes develop pancreatic cancer twice as often as nondiabetics. Numerous studies suggest that a family history of pancreatic cancer is another strong risk factor for developing the disease, particularly if two or more relatives in the immediate family have the disease. Other risk factors include chronic (long-term) inflammation of the pancreas (pancreatitis), diets high in fat, and occupational exposure to certain chemicals such as petroleum.

Pancreatic cancer often does not produce symptoms until it reaches an advanced stage. Patients may then present with the following signs and symptoms:

• upper abdominal and/or back pain
• jaundice
• weight loss
• loss of appetite (anorexia )
• diarrhea
• weakness
• nausea

These symptoms may also be caused by other illnesses; therefore, it is important to consult a doctor for an accurate diagnosis.

Diagnosis

Pancreatic cancer is difficult to diagnose, especially in the absence of symptoms, and there is no current screening method for early detection. The most sophisticated techniques available often do not detect very small tumors that are localized (have not begun to spread). At advanced stages where patients show symptoms, a number of tests may be performed to confirm diagnosis and to assess the stage of the disease. Approximately half of all pancreatic cancers are metastatic (have spread to other sites) at the time of diagnosis.

The first step in diagnosing pancreatic cancer is a thorough medical history and complete physical examination. The abdomen will be palpated to check for fluid accumulation, lumps, or masses. If there are signs of jaundice, blood tests will be performed to rule out the possibility of liver diseases such as hepatitis. Urine and stool tests may be performed as well.

Non-invasive imaging tools such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be used to produce detailed pictures of the internal organs. CT is the tool most often used to diagnose pancreatic cancer, as it allows the doctor to determine if the tumor can be removed by surgery or not. It is also useful in staging a tumor by showing the extent to which the tumor has spread. During a CT scan, patients receive an intravenous injection of a contrast dye so the organs can be visualized more clearly. MRI may be performed instead of CT if a patient has an allergy to the CT contrast dye. In some cases where the tumor is impinging on blood vessels or nearby ducts, MRI may be used to generate an image of the pancreatic ducts.

If the doctor suspects pancreatic cancer and no visible masses are seen with a CT scan, a patient may undergo a combination of invasive tests to confirm the presence of a pancreatic tumor. Endoscopic ultrasound (EUS) involves the use of an ultrasound probe at the end of a long, flexible tube that is passed down the patient's throat and into the stomach. This instrument can detect a tumor mass through high frequency sound waves and echoes. EUS can be accompanied by fine needle aspiration (FNA), where a long needle, guided by the ultrasound, is inserted into the tumor mass in order to take a biopsy sample. Endoscopic retrograde cholangiopancreatography (ERCP) is a technique often used in patients with severe jaundice because it enables the doctor to relieve blockage of the pancreatic ducts. The doctor, guided by endoscopy and x rays, inserts a small metal or plastic stent into the duct to keep it open. During ERCP, a biopsy can be done by collecting cells from the pancreas with a small brush. The cells are then examined under the microscope by a pathologist, who determines the presence of any cancerous cells.

In some cases, a biopsy may be performed during a type of surgery called laparoscopy , which is done under general anesthesia. Doctors insert a small camera and instruments into the abdomen after a minor incision is made. Tissue samples are removed for examination under the microscope. This procedure allows a doctor to determine the extent to which the disease has spread and decide if the tumor can be removed by further surgery.

An angiography is a type of test that studies the blood vessels in and around the pancreas. This test may be done before surgery so that the doctor can determine the extent to which the tumor invades and interacts with the blood vessels within the pancreas. The test requires local anesthesia and a catheter is inserted into the patient's upper thigh. A dye is then injected into blood vessels that lead into the pancreas, and x rays are taken.

As of April 2001, doctors at major cancer research institutions such as Memorial Sloan-Kettering Cancer Center in New York were investigating CT angiography, an imaging technique that is less invasive than angiography alone. CT angiography is similar to a standard CT scan, but allows doctors to take a series of pictures of the blood vessels that support tumor growth. A dye is injected as in a CT scan (but at rapid intervals) and no catheter or sedation is required. A computer generates 3D images from the pictures that are taken, and the information is gathered by the surgical team who will develop an appropriate strategy if the patient's disease can be operated on.

Treatment team

Pancreatic cancer is a complex disease that involves specialists from a variety of medical disciplines. Patients are likely to interact with medical oncologists, gastroenterologists, radiologists, and surgeons to develop a suitable treatment plan. Treatment plans vary depending on the stage of the disease and the overall health of the patient. Cancers of the pancreas frequently cause intense pain by pressing on the surrounding network of nerves in the abdomen; therefore, anesthesiologists who specialize in pain management may play a role in making a patient more comfortable. Obstruction of the intestine or bowel can also be a cause of pain, but is usually relieved through surgery. Patients receiving chemotherapy meet with oncologists who determine the dose schedule and oncology nurses who administer the chemotherapy. Patients who undergo partial or total removal of their pancreas may develop diabetes, and an endocrinologist will prescribe insulin or other medication to help them manage this condition. It is important for patients to get proper nutrition during any treatment for cancer. Patients may wish to consult a nutritionist or dietician to assist them (this may require oral replacement of digestive enzymes).

Clinical staging, treatments, and prognosis

Staging

After cancer of the pancreas has been diagnosed, doctors typically use a TNM staging system to classify the tumor based on its size and the degree to which it has spread to other areas in the body. T indicates the size and local advancement of the primary tumor. Since cancers often invade the lymphatic system before spreading to other organs, regional lymph node involvement (N) is an important factor in staging. M indicates whether the tumor has metastasized (spread) to distant organs. In stage I, the tumor is localized to the pancreas and has not spread to surrounding lymph nodes or other organs. Stage II pancreatic cancer has spread to nearby organs such as the small intestine or bile duct, but not the surrounding lymph nodes. Stage III indicates lymph node involvement, whether the cancer has spread to nearby organs or not. Stage IVA pancreatic cancer has spread to organs near the pancreas such as the stomach, spleen, or colon. Stage IVB is a cancer that has spread to distant sites (liver, lung). If pancreatic cancer has been treated with success and then appears again in the pancreas or in other organs, it is referred to as recurrent disease.

Treatments

Treatment of pancreatic cancer will depend on several factors, including the stage of the disease and the patient's age and overall health status. A combination of therapies is often employed in the treatment of this disease to improve the patient's chances for survival. Surgery is used whenever possible and is the only means by which cancer of the pancreas can be cured. However, less than 15% of pancreatic tumors can be removed by surgery. By the time the disease is diagnosed (usually at Stage III), therapies such as radiation and chemotherapy or both are used in addition to surgery to relieve a patient's symptoms and enhance quality of life. For patients with metastatic disease, chemotherapy and radiation are used mainly as palliative (pain-alleviating) treatments.

SURGERY.

Three types of surgery are used in the treatment of pancreatic cancer, depending on what section of the pancreas the tumor is located in. A Whipple procedure removes the head of the pancreas, part of the small intestine and some of the surrounding tissues. This procedure is most common since the majority of pancreatic cancers occur in the head of the organ. A total pancreatectomy removes the entire pancreas and the organs around it. Distal pancreatectomy removes only the body and tail of the pancreas. Chemotherapy and radiation may precede surgery (neoadjuvant therapy) or follow surgery (adjuvant therapy). Surgery is also used to relieve symptoms of pancreatic cancer by draining fluids or bypassing obstructions. Side effects from surgery can include pain, weakness, fatigue , and digestive problems. Some patients may develop diabetes or malabsorption as a result of partial or total removal of the pancreas.

RADIATION THERAPY.

Radiation therapy is sometimes used to shrink a tumor before surgery or to remove remaining cancer cells after surgery. Radiation may also be used to relieve pain or digestive problems caused by the tumor if it cannot be removed by surgery. External radiation therapy refers to radiation applied externally to the abdomen using a beam of high-energy x rays. High-dose intraoperative radiation therapy is sometimes used during surgery on tumors that have spread to nearby organs. Internal radiation therapy refers to the use of small radioactive seeds implanted in the tumor tissue. The seeds emit radiation over a period of time to kill tumor cells. Radiation treatment may cause side effects such as fatigue, tender or itchy skin, nausea, vomiting, and digestive problems.

CHEMOTHERAPY.

Chemotherapeutic agents are powerful drugs that are used to kill cancer cells. They are classified according to the mechanism by which they induce cancer cell death. Multiple agents are often used to increase the chances of tumor cell death. Gemcitabine is the standard drug used to treat pancreatic cancers and can be used alone or in combination with other drugs, such as fluorouracil (5-FU). Other drugs are being tested in combination with gemcitabine in several ongoing clinical trials , specifically irinotecan (CPT-11) and oxaliplatin . Chemotherapy may be administered orally or intravenously in a series of doses over several weeks. During treatment, patients may experience fatigue, nausea, vomiting, hair loss (alopecia ), and mouth sores, depending on which drugs are used.

BIOLOGICAL TREATMENTS.

Numerous vaccine treatments are being developed in an effort to stimulate the body's immune system into attacking cancer cells. This is also referred to as immunotherapy. Another type of biological treatment involves using a targeted monoclonal antibody to inhibit the growth of cancer cells. The antibody is thought to bind to and neutralize a protein that contributes to the growth of the cancer cells. Investigational treatments such as these may be considered by patients with metastatic disease who would like to participate in a clinical trial. Biological treatments typically cause flu-like symptoms (chills, fever , loss of appetite) during the treatment period.

Prognosis

Unfortunately, cancer of the pancreas is often fatal, and median survival from diagnosis is less than six months, while the five-year survival rate is 4%. This is mainly due to the lack of screening methods available for early detection of the disease. Yet, even when localized tumors can be removed by surgery, patient survival after five years is only 10% to 15%. These statistics demonstrate the aggressive nature of most pancreatic cancers and their tendency to recur. Pancreatic cancers tend to be resistant to radiation and chemotherapy and these modes of treatment are mainly used to relieve pain and tumor burden.

Alternative and complementary therapies

Acupuncture or hypnotherapy may be used in addition to standard therapies to help relieve the pain associated with pancreatic cancer. Because of the poor prognosis associated with pancreatic cancer, some patients may try special diets with vitamin supplements, certain exercise programs, or unconventional treatments not yet approved by the FDA. Patients should always inform their doctors of any alternative treatments they are using as they could interfere with standard therapies. As of 2000, the National Cancer Institute (NCI) was funding phase III clinical trials of a controversial treatment for pancreatic cancer that involves the use of supplemental pancreatic enzymes (to digest cancerous cells) and coffee enemas (to stimulate the liver to detoxify the cancer). These theories remain unproven and the study is widely criticized in the medical community. It remains to been seen whether this method of treatment has any advantage over the standard chemotherapeutic regimen in prolonging patient survival or improving quality of life.

Coping with cancer treatment

Patients should discuss with their doctors any side effects they experience from treatment. Many drugs are available to relieve nausea and vomiting associated with cancer treatments and for combating fatigue. Special diets or supplements, including pancreatic enzymes, may be recommended if patients are experiencing digestive problems. Insulin or other medication may be prescribed if patients develop diabetes as a result of partial or total removal of their pancreas.

Clinical trials

A large number of clinical trials are underway to assess the therapeutic effect of new chemotherapy regimens and several new immunotherapies. Gemcitabine is being tested in combination with irinotecan (CPT-11) in patients with metastatic pancreatic disease. Other agents under investigation are DX-8951f and R115777. Some drugs are being tested in combination with radiation therapy or with biological therapies. Two preliminary studies using the vaccine G17DT showed a significant improvement in the survival of patients with advanced pancreatic cancer. The monoclonal antibody cetuximab (IMCC225) in combination with gemcitabine also showed positive preliminary results. There are trials available for patients with all stages of pancreatic cancer. Patients can find out which trials they are eligible for by talking with their doctors. Information about ongoing trials can be found at <http://cancernet.nci.nih.gov/trialsrch.shtml>. Many treatments given during clinical trials are considered experimental by health insurance companies and may not be covered by certain health plans. Patients should discuss their options with their doctor and health insurance provider.

Prevention

Although the exact cause of pancreatic cancer is not known, there are certain risk factors that may increase a person's chances of developing the disease. Quitting smoking will certainly reduce the risk for pancreatic cancer and many other cancers. The American Cancer Society recommends a diet rich in fruits, vegetables, and dietary fiber in order to reduce the risk of pancreatic cancer. According to the National Cancer Institute, workers who are exposed to petroleum and other chemicals may be at greater risk for developing the disease and should follow their employer's safety precautions. People with a family history of pancreatic cancer are at greater risk than the general population, as a small percentage of pancreatic cancers are considered hereditary.

Special concerns

Pain control is probably the single greatest problem for patients with pancreatic cancer. As the cancer grows and spreads to other organs in the abdomen, it often presses on the surrounding network of nerves, which can cause considerable discomfort. In most cases, pain can be alleviated with analgesics or opioids . If medication is not enough, a doctor may inject alcohol into the abdominal nerve area to numb the pain. Surgical treatment of the affected nerves is also an option.

Pancreatic cancer patients frequently have difficulty maintaining their weight because food may not taste good or the pancreas is not releasing enough enzymes needed for digestion. Therefore, supplements of pancreatic enzymes may be helpful in restoring proper digestion. Other nutritional supplements may be given orally or intravenously in an effort to boost calorie intake. However, cachexia (severe muscle breakdown) caused by certain substances that the cancer produces, remains a significant problem to treat.

Patients with pancreatic cancer may experience anxiety and depression during their diagnosis and treatment. Statistics on the prognosis for the disease can be discouraging, however, there are many new treatments on the horizon that may significantly improve the outcome for this disease. Many patients find it helpful to join support groups where they can discuss their concerns with others who are also coping with the illness.

See Also Drug resistance; Gastrointestinal cancers; Nutritional support; Pain management; Pancreatic cancer, endocrine; Immunologic therapies; Cigarettes; smoking cessation

Resources

BOOKS

Beger, Hans G., et al., ed. The Pancreas. 2 vols. Oxford: Blackwell Science Ltd., 1998.

Reber, Howard A. ed. Pancreatic Cancer: Pathogenesis, Diag nosis, and Treatment. Totowa: Humana Press, 1998.

Teeley, Peter, and Philip Bashe. The Complete Cancer Survival Guide. New York: Doubleday, 2000.

PERIODICALS

Bornman, P.C., and I.J. Beckingham. "ABC of Diseases of Liver, Pancreas, and Biliary System. Pancreatic Tumours." British Medical Journal 322, no. 7288 (24 March 2001):721-3.

Haut, E., A. Abbas, and A. Schuricht. "Pancreatic Cancer: The Role of the Primary Care Physican." Consultant 39, no. 12 (December 1999): 3329.

Parks, R.W., and O.J. Garden. "Ensuring Early Diagnosis in Pancreatic Cancer." Practitioner 244, no. 1609 (April 2000): 336-8, 340-1, 343.

ORGANIZATIONS

CancerNet. National Cancer Institute, 9000 Rockville Pike, Bldg.31, Rm.10A16, Bethesda, Maryland, 20892. (800) 422-6237. <http://wwwicic.nci.nih.gov>

Hirshberg Foundation for Pancreatic Cancer Research. 375 Homewood Rd., Los Angeles, CA 90049. (310) 472-6310. <http://www.pancreatic.org>

National Pancreas Foundation. PO Box 935, Wexford, PA 15090-0935. <http://www.pancreasfoundation.org>

Pancreatic Cancer Action Network. PO Box 1010, Torrance, CA 90505. (877) 272-6226. <http://www.pancan.org>

OTHER

University of Texas MD Anderson Cancer Center. Pancreatic Tumor Study Group. 20 July 2001 <http://www.mdanderson.org/DEPARTMENTS/pancreatic/>

"What You Need To Know About Cancer of the Pancreas." National Cancer Institute. December 12, 2000. 20 July 2001 <http://cancernet.nci.nih.gov/wyntk_pubs/pancreas.htm>

Johns Hopkins Medical Institutions. 20 July 2001 <http://www.path.jhu.edu/pancreas>

Memorial Sloan-Kettering Cancer Center. Patient Information on Pancreatic Cancer. 20 July 2001 <http://www.mskcc.org/patients_n_public/about_cancer_and_treatment/cancer_information_by_type/pancreatic_cancer/index.html>

Lata Cherath Ph.D.

Elizabeth Pulcini, M.Sc.

KEY TERMS

Acinar cell (s)

—Cells that comprise small sacs terminating the ducts of some exocrine glands.

Acinar cell carcinoma

—A malignant tumor arising from the acinar cells of the pancreas.

Angiography

—Diagnostic technique used to study blood vessels in a tumor.

Biopsy

—Removal and microscopic examination of cells to determine whether they are cancerous.

Cancer vaccines

—A treatment that uses the patient's immune system to attack cancer cells.

Chemotherapy

— Drug treatment administered to kill cancerous cells.

Ductal adenocarcinoma

—A malignant tumor arising from the duct cells within a gland.

Endoscopic retrograde cholangiopancreatography (ERCP)

—Diagnostic technique used to obtain a biopsy. Also a surgical method of relieving biliary obstruction caused by a tumor.

Endoscopic ultrasonography (EUS)

—Diagnostic imaging technique in which an ultrasound probe is inserted down a patient's throat to determine if a tumor is present.

Exocrine

—Refers to glands which secrete their products through a duct.

Laparoscopic surgery

—Minimally invasive surgery in which a camera and surgical instruments are inserted through a small incision.

Pancreatectomy

—Partial or total surgical removal of the pancreas.

Radiation therapy

—Use of radioisotopes to kill tumor cells. Applied externally through a beam of x rays, intraoperatively (during surgery), or deposited internally by implanting radioactive seeds in tumor tissue.

Whipple procedure

—Surgical removal of the head of the pancreas, part of the small intestine, and some surrounding tissue.

QUESTIONS TO ASK THE DOCTOR

• What is my prognosis?
• What is the standard course of treatment for my cancer at this stage?
• How long will the course of treatment take?
• What side effects will I experience?
• What can be done to relieve my abdominal pain?
• What should I do to prepare for surgery?
• Can you refer me to a nutritionist or dietician?
• Are there any alternative therapies you would recommend?
• Am I eligible to participate in a clinical trial?
• Will my health insurance cover costs associated with a clinical trial?
• Are there any support groups I can join?

Pancreatic Cancer, Exocrine

Definition

Exocrine pancreatic cancer is a disease in which cancerous cells originate within the tissues of the pancreas that produce digestive juices.

Description

The pancreas is a six- to eight-inch long, slipper-shaped gland located in the abdomen. It lies behind the stomach, within a loop formed by the small intestine. Other nearby organs include the gallbladder, spleen, and liver. The pancreas has a wide end (head), a narrow end (tail) and a middle section (body). A healthy pancreas is important for normal food digestion and also plays a critical role in the body's metabolic processes. The pancreas has two main functions, and each are performed by distinct types of tissue. The exocrine tissue makes up the vast majority of the gland and secretes fluids into the other organs of the digestive system. The endocrine tissue secretes hormones (like insulin ) that are circulated in the bloodstream, and these substances control how the body stores and uses nutrients. The exocrine tissue of the pancreas produces pancreatic (digestive) juices. These juices contain several enzymes that help break down proteins and fatty foods. The exocrine pancreas forms an intricate system of channels or ducts, which are tubular structures that carry pancreatic juices to the small intestine where they are used for digestion.

Pancreatic tumors are classified as either exocrine or endocrine tumors depending on which type of tissue they arise from within the gland. Ninety-five percent of pancreatic cancers occur in the tissues of the exocrine pancreas. Ductal adenocarcinomas arise in the cells that line the ducts of the exocrine pancreas and account for 80–90% of all tumors of the pancreas. Unless specified, nearly all reports on pancreatic cancer refer to ductal adenocarcinomas. Less common types of pancreatic exocrine tumors include acinar cell carcinoma, cystic tumors that are typically benign but may become cancerous, and papillary tumors that grow within the pancreatic ducts. Pancreatoblastoma is a very rare disease that primarily affects young children. Two-thirds of pancreatic tumors occur in the head of the pancreas, and tumor growth in this area can lead to the obstruction of the nearby common bile duct that empties bile fluid into the small intestine. When bile cannot be passed into the intestine, patients may develop yellowing of the skin and eyes (jaundice) due to the buildup of bilirubin (a component of bile) in the bloodstream. Tumor blockage of bile or pancreatic ducts may also cause digestive problems since these fluids contain critical enzymes in the digestive process. Depending on their size, pancreatic tumors may cause abdominal pain by pressing on the surrounding nerves. Because of its location deep within the abdomen, pancreatic cancer often remains undetected until it has spread to other organs such as the liver or lung. Pancreatic cancer tends to rapidly spread to other organs, even when the primary (original) tumor is relatively small.

Demographics

Though pancreatic cancer accounts for only 3% of all cancers, it is the fifth most frequent cause of cancer deaths. In 2008, an estimated 37,680 new cases of pancreatic cancer will be diagnosed in the United States. Pancreatic cancer is primarily a disease associated with advanced age, with 80% of cases occurring between the ages of 60 and 80. Men are almost twice as likely to develop this disease than women. Countries with the highest frequencies of pancreatic cancer include the U.S., New Zealand, Western European nations, and Scandinavia. The lowest occurrences of the disease are reported in India, Kuwait and Singapore. African Americans have the highest rate of pancreatic cancer of any ethnic group worldwide. Whether this difference is due to diet or environmental factors remains unclear.

Causes and symptoms

Although the exact cause for pancreatic cancer is not known, several risk factors have been shown to increase susceptibility to this particular cancer, the greatest of which is cigarette smoking . Approximately one-third of pancreatic cancer cases occur among smokers. People who have diabetes develop pancreatic cancer twice as often as non-diabetics. Numerous studies suggest that a family history of pancreatic cancer is another strong risk factor for developing the disease, particularly if two or more relatives in the immediate family have the disease. Other risk factors include chronic (long-term) inflammation of the pancreas (pancreatitis), diets high in fat, and occupational exposure to certain chemicals such as petroleum.

Pancreatic cancer often does not produce symptoms until it reaches an advanced stage. Patients may then present with the following signs and symptoms:

• upper abdominal and/or back pain
• jaundice
• weight loss
• loss of appetite (anorexia)
• diarrhea
• weakness
• nausea

These symptoms may also be caused by other illnesses; therefore, it is important to consult a doctor for an accurate diagnosis.

Diagnosis

Pancreatic cancer is difficult to diagnose, especially in the absence of symptoms, and there is no current screening method for early detection. The most sophisticated techniques available often do not detect very small tumors that are localized (have not begun to spread). At advanced stages where patients show symptoms, a number of tests may be performed to confirm diagnosis and to assess the stage of the disease. Approximately half of all pancreatic cancers are metastatic (have spread to other sites) at the time of diagnosis.

The first step in diagnosing pancreatic cancer is a thorough medical history and complete physical examination. The abdomen will be palpated to check for fluid accumulation, lumps, or masses. If there are signs of jaundice, blood tests will be performed to rule out the possibility of liver diseases such as hepatitis . Urine and stool tests may be performed as well.

Non-invasive imaging tools such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be used to produce detailed pictures of the internal organs. CT is the tool most often used to diagnose pancreatic cancer, as it allows the doctor to determine if the tumor can be removed by surgery or not. It is also useful in staging a tumor by showing the extent to which the tumor has spread. During a CT scan, patients receive an intravenous injection of a contrast dye so the organs can be visualized more clearly. MRI may be performed instead of CT if a patient has an allergy to the CT contrast dye. In some cases where the tumor is impinging on blood vessels or nearby ducts, MRI may be used to generate an image of the pancreatic ducts.

If the doctor suspects pancreatic cancer and no visible masses are seen with a CT scan, a patient may undergo a combination of invasive tests to confirm the presence of a pancreatic tumor. Endoscopic ultrasound (EUS) involves the use of an ultrasound probe at the end of a long, flexible tube that is passed down the patient's throat and into the stomach. This instrument can detect a tumor mass through high frequency sound waves and echoes. EUS can be accompanied by fine needle aspiration (FNA), where a long needle, guided by the ultrasound, is inserted into the tumor mass in order to take a biopsy sample. Endoscopic retrograde cholangiopancreatography (ERCP) is a technique often used in patients with severe jaundice because it enables the doctor to relieve blockage of the pancreatic ducts. The doctor, guided by endoscopy and x rays, inserts a small metal or plastic stent into the duct to keep it open. During ERCP, a biopsy can be done by collecting cells from the pancreas with a small brush. The cells are then examined under the microscope by a pathologist, who determines the presence of any cancerous cells.

In some cases, a biopsy may be performed during a type of surgery called laparoscopy, which is done under general anesthesia . Doctors insert a small camera and instruments into the abdomen after a minor incision is made. Tissue samples are removed for examination under the microscope. This procedure allows a doctor to determine the extent to which the disease has spread and decide if the tumor can be removed by further surgery.

An angiography is a type of test that studies the blood vessels in and around the pancreas. This test may be done before surgery so that the doctor can determine the extent to which the tumor invades and interacts with the blood vessels within the pancreas. The test requires local anesthesia and a catheter is inserted into the patient's upper thigh. A dye is then injected into blood vessels that lead into the pancreas, and x rays are taken.

Doctors at major cancer research institutions such as Memorial Sloan-Kettering Cancer Center in New York are investigating CT angiography, an imaging technique that is less invasive than angiography alone. CT angiography is similar to a standard CT scan, but allows doctors to take a series of pictures of the blood vessels that support tumor growth. A dye is injected as in a CT scan (but at rapid intervals) and no catheter or sedation is required. A computer generates 3D images from the pictures that are taken, and the information is gathered by the surgical team who will develop an appropriate strategy if the patient's disease can be operated on.

Treatment team

Pancreatic cancer is a complex disease that involves specialists from a variety of medical disciplines. Patients are likely to interact with medical oncologists, gastroenterologists, radiologists, and surgeons to develop a suitable treatment plan.Treatment plans vary depending on the stage of the disease and the overall health of the patient. Cancers of the pancreas frequently cause intense pain by pressing on the surrounding network of nerves in the abdomen; therefore, anesthesiologists who specialize in pain management may play a role in making a patient more comfortable. Obstruction of the intestine or bowel can also be a cause of pain, but is usually relieved through surgery. Patients receiving chemotherapy meet with oncologists who determine the dose schedule and oncology nurses who administer the chemotherapy. Patients who undergo partial or total removal of their pancreas may develop diabetes, and an endocrinologist will prescribe insulin or other medication to help them manage this condition. It is important for patients to get proper nutrition during any treatment for cancer. Patients may wish to consult a nutritionist or dietician to assist them (this may require oral replacement of digestive enzymes).

Clinical staging, treatments, and prognosis

Staging

After cancer of the pancreas has been diagnosed, doctors typically use a TNM staging system to classify the tumor based on its size and the degree to which it has spread to other areas in the body. T indicates the size and local advancement of the primary tumor. Since cancers often invade the lymphatic system before spreading to other organs, regional lymph node involvement (N) is an important factor in staging. M indicates whether the tumor has metastasized (spread) to distant organs. In stage I, the tumor is localized to the pancreas and has not spread to surrounding lymph nodes or other organs. Stage II pancreatic cancer has spread to nearby organs such as the small intestine or bile duct, but not the surrounding lymph nodes. Stage III indicates lymph node involvement, whether the cancer has spread to nearby organs or not. Stage IVA pancreatic cancer has spread to organs near the pancreas such as the stomach, spleen, or colon. Stage IVB is a cancer that has spread to distant sites (liver, lung). If pancreatic cancer has been treated with success and then appears again in the pancreas or in other organs, it is referred to as recurrent disease.

Treatment

Treatment of pancreatic cancer will depend on several factors, including the stage of the disease and the patient's age and overall health status. A combination of therapies is often employed in the treatment of this disease to improve the patient's chances for survival. Surgery is used whenever possible and is the only means by which cancer of the pancreas can be cured. However, less than 15% of pancreatic tumors can be removed by surgery. By the time the disease is diagnosed (usually at Stage III), therapies such as radiation and chemotherapy or both are used in addition to surgery to relieve a patient's symptoms and enhance quality of life. For patients with metastatic disease, chemotherapy and radiation are used mainly as palliative (pain-alleviating) treatments.

SURGERY Three types of surgery are used in the treatment of pancreatic cancer, depending on what section of the pancreas the tumor is located in. A Whipple procedure removes the head of the pancreas, part of the small intestine and some of the surrounding tissues. This procedure is most common since the majority of pancreatic cancers occur in the head of the organ. A total pancreatectomy removes the entire pancreas and the organs around it. Distal pancreatectomy removes only the body and tail of the pancreas. Chemotherapy and radiation may precede surgery (neoadjuvant therapy) or follow surgery (adjuvant therapy). Surgery is also used to relieve symptoms of pancreatic cancer by draining fluids or bypassing obstructions. Side effects from surgery can include pain, weakness, fatigue, and digestive problems. Some patients may develop diabetes or malabsorption as a result of partial or total removal of the pancreas.

RADIATION THERAPY Radiation therapy is sometimes used to shrink a tumor before surgery or to remove remaining cancer cells after surgery. Radiation may also be used to relieve pain or digestive problems caused by the tumor if it cannot be removed by surgery. External radiation therapy refers to radiation applied externally to the abdomen using a beam of high-energy x rays. High-dose intraoperative radiation therapy is sometimes used during surgery on tumors that have spread to nearby organs. Internal radiation therapy refers to the use of small radioactive seeds implanted in the tumor tissue. The seeds emit radiation over a period of time to kill tumor cells. Radiation treatment may cause side effects such as fatigue, tender or itchy skin, nausea, vomiting, and digestive problems.

CHEMOTHERAPY Chemotherapeutic agents are powerful drugs that are used to kill cancer cells. They are classified according to the mechanism by which they induce cancer cell death . Multiple agents are often used to increase the chances of tumor cell death. Gemcitabine is the standard drug used to treat pancreatic cancers and can be used alone or in combination with other drugs, such as 5-fluorouracil (5-FU, or fluorouracil). Other drugs are being tested in combination with gemcitabine in several ongoing clinical trials, specifically irinotecan (CPT-11) and oxaliplatin. Chemotherapy may be administered orally or intravenously in a series of doses over several weeks. During treatment, patients may experience fatigue, nausea, vomiting, hair loss (alopecia ), and mouth sores, depending on which drugs are used.

BIOLOGICAL TREATMENTS Numerous vaccine treatments are being developed in an effort to stimulate the body's immune system into attacking cancer cells. This is also referred to as immunotherapy. Another type of biological treatment involves using a targeted monoclonal antibody to inhibit the growth of cancer cells. The antibody is thought to bind to and neutralize a protein that contributes to the growth of the cancer cells. Investigational treatments such as these may be considered by patients with metastatic disease who would like to participate in a clinical trial. Biological treatments typically cause flu-like symptoms (chills, fever, loss of appetite) during the treatment period.

Prognosis

Cancer of the pancreas is often fatal, and median survival from diagnosis is less than six months, while the five-year survival rate is 5%. This is mainly due to the lack of screening methods available for early detection of the disease. When localized tumors can be removed by surgery, patient survival after five years is only 15–20%. These statistics demonstrate the aggressive nature of most pancreatic cancers and their tendency to recur. Pancreatic cancers tend to be resistant to radiation and chemotherapy and these modes of treatment are mainly used to relieve pain and tumor burden.

Nutrition/Dietetic concerns

Because of the poor prognosis associated with pancreatic cancer, some patients may try special diets with vitamin supplements, certain exercise programs, or unconventional treatments not yet approved by the FDA. Patients should always inform their doctors of any alternative treatments they are using as they could interfere with standard therapies. As of 2000, the National Cancer Institute (NCI) was funding phase III clinical trials of a controversial treatment for pancreatic cancer that involves the use of supplemental pancreatic enzymes (to digest cancerous cells) and coffee enemas (to stimulate the liver to detoxify the cancer). These theories remain unproven and the study is widely criticized in the medical community. It remains to been seen whether this method of treatment has any advantage over the standard chemotherapeutic regimen in prolonging patient survival or improving quality of life.

KEY TERMS

Acinar cell(s) —Cells that comprise small sacs terminating the ducts of some exocrine glands.

Acinar cell carcinoma —A malignant tumor arising from the acinar cells of the pancreas.

Ductal adenocarcinoma —A malignant tumor arising from the duct cells within a gland.

Endoscopic retrograde cholangiopancreatography (ERCP) —Diagnostic technique used to obtain a biopsy. Also a surgical method of relieving biliary obstruction caused by a tumor.

Endoscopic ultrasonography (EUS) —Diagnostic imaging technique in which an ultrasound probe is inserted down a patient's throat to determine if a tumor is present.

Exocrine —Refers to glands which secrete their products through a duct.

Laparoscopic surgery —Minimally invasive surgery in which a camera and surgical instruments are inserted through a small incision.

Pancreatectomy —Partial or total surgical removal of the pancreas.

Radiation therapy —Use of radioisotopes to kill tumor cells. Applied externally through a beam of x rays, intraoperatively (during surgery), or deposited internally by implanting radioactive seeds in tumor tissue.

Whipple procedure —Surgical removal of the head of the pancreas, part of the small intestine, and some surrounding tissue.

Pancreatic cancer patients frequently have difficulty maintaining their weight because food may not taste good or the pancreas is not releasing enough enzymes needed for digestion. Therefore, supplements of pancreatic enzymes may be helpful in restoring proper digestion. Other nutritional supplements may be given orally or intravenously in an effort to boost calorie intake. However, cachexia (severe muscle breakdown) caused by certain substances that the cancer produces, remains a significant problemto treat.

Caregiver concerns

Patients should discuss with their doctors any side effects they experience from treatment. Many drugs are available to relieve nausea and vomiting

QUESTIONS TO ASK THE DOCTOR

• What is my prognosis?
• What is the standard course of treatment for my cancer at this stage?
• How long will the course of treatment take?
• What side effects will I experience?
• What can be done to relieve my abdominal pain?
• What should I do to prepare for surgery?
• Can you refer me to a nutritionist or dietician?
• Are there any alternative therapies you would recommend?
• Am I eligible to participate in a clinical trial?
• Will my health insurance cover costs associated with a clinical trial?
• Are there any support groups I can join?

associated with cancer treatments and for combating fatigue. Special diets or supplements, including pancreatic enzymes, may be recommended if patients are experiencing digestive problems. Insulin or other medication may be prescribed if patients develop diabetes as a result of partial or total removal of their pancreas.

Prevention

Although the exact cause of pancreatic cancer is not known, there are certain risk factors that may increase a person's chances of developing the disease. Quitting smoking will certainly reduce the risk for pancreatic cancer and many other cancers. The American Cancer Society recommends a diet rich in fruits, vegetables, and dietary fiber in order to reduce the risk of pancreatic cancer. According to the NCI, workers who are exposed to petroleum and other chemicals may be at greater risk for developing the disease and should follow their employer's safety precautions. People with a family history of pancreatic cancer are at greater risk than the general population, as a small percentage of pancreatic cancers are considered hereditary.

Resources

BOOKS

Teeley, Peter, and Philip Bashe. The Complete Cancer Survival Guide. New York: Doubleday, 2000.

PERIODICALS

Bornman, P.C., and I.J. Beckingham. “ABC of Diseases of Liver, Pancreas, and Biliary System. Pancreatic Tumours.” British Medical Journal 322, no. 7288 (March 24, 2001): 721–3.

Haut, E., A. Abbas, and A. Schuricht. “Pancreatic Cancer: The Role of the Primary Care Physican.” Consultant 39, no. 12 (December 1999): 3329.

Parks, R.W., and O.J. Garden. “Ensuring Early Diagnosis in Pancreatic Cancer.” Practitioner 244, no. 1609 (April 2000): 336–8, 340–1, 343.

ORGANIZATIONS

CancerNet. National Cancer Institute, 9000 Rockville Pike, Bldg.31, Rm.10A16, Bethesda, Maryland, 20892. (800) 422-6237. http://wwwicic.nci.nih.gov.

Hirshberg Foundation for Pancreatic Cancer Research. 375 Homewood Rd., Los Angeles, CA 90049. (310) 472 6310. http://www.pancreatic.org.

National Pancreas Foundation. PO Box 935, Wexford, PA 15090-0935. http://www.pancreasfoundation.org.

Pancreatic Cancer Action Network. PO Box 1010, Torrance, CA 90505. (877) 272-6226. http://www.pancan.org.

OTHER

Johns Hopkins Medical Institutions. [cited July 20, 2001]. http://www.path.jhu.edu/pancreas.

Memorial Sloan-Kettering Cancer Center. Patient Information on Pancreatic Cancer. [cited July 20, 2001]. http://www.mskcc.org/patients_n_public/about_cancer_and_treatment/cancer_information_by_type/pancreatic_cancer/index.html.

University of Texas MD Anderson Cancer Center. Pancreatic Tumor Study Group. [cited July 20, 2001]. http://www.mdanderson.org/DEPARTMENTS/pancreatic/.

“What You Need To Know About Cancer of the Pancreas.” National Cancer Institute. December 12, 2000. [cited July 20, 2001]. http://cancernet.nci.nih.gov/wyntk_pubs/pancreas.htm.

Lata Cherath Ph.D.

Elizabeth Pulcini M.Sc.

Pancreatic Cancer, Endocrine

Definition

Endocrine pancreatic cancer is a disease in which cancerous cells originate within the tissues of the pancreas that produce hormones.

Description

The pancreas is a 6-8 in (15-20 cm) long, slipper-shaped gland located in the abdomen. It lies behind the stomach, within a loop formed by the small intestine. Other nearby organs include the gallbladder, spleen, and liver. The pancreas has a wide end (head), a narrow end (tail), and a middle section (body). A healthy pancreas is important for normal food digestion and plays a critical role in the body's metabolic processes. The pancreas has two main functions, each performed by distinct types of tissue. The exocrine tissue secretes fluids into the other organs of the digestive system, while the endocrine tissue secretes substances that are circulated in the bloodstream. The exocrine pancreas makes up the vast majority of the gland; it produces pancreatic juices containing enzymes that help break down proteins and fatty food. The endocrine tissue of the pancreas makes up only 2% of the gland's total mass. It consists of small patches of cells that produce hormones (like insulin) that control how the body stores and uses nutrients. These patches are called islets (islands) of Langerhans or islet cells and are interspersed evenly throughout the pancreas. Each islet contains approximately 1,000 endocrine cells and a dense network of capillaries (tiny blood vessels), which allows immediate entry of hormones into the circulatory system.

Pancreatic tumors are classified as either exocrine or endocrine tumors depending on which type of tissue they arise from within the gland. Endocrine tumors of the pancreas are very rare, accounting for only 5% of all pancreatic cancers. The majority of endocrine pancreatic tumors are functional adenocarcinomas that overproduce a specific hormone. There are several types of islet cells and each produces its own hormone or peptide (small protein molecule). Functional endocrine tumors are named after the hormone they secrete. Insulinoma is the most common tumor of the endocrine pancreas. Patients with this disease usually develop hypoglycemia due to increased insulin production that leads to abnormally low blood sugar levels. Gastrinoma, a disease in which gastrin (hormone that stimulates stomach acid production) is overproduced, causes multiple ulcers in the upper gastrointestinal (GI) tract. Gastrinoma was first described in patients with a rare form of severe peptic ulcer disease known as Zollinger-Ellison syndrome (ZES). The less common glucagonoma causes mild diabetes due to excess glucagon (hormone that stimulates glucose production) secretion. Other rare islet cell tumors include vipoma (vasoactive intestinal peptide) and somatostatinoma. Nonfunctional pancreatic endocrine tumors are not associated with an excess production of any hormone and can be difficult to distinguish from exocrine pancreatic cancer. Cancers of the endocrine pancreas are relatively slow-growing compared to the more common ductal adenocarcinomas of the exocrine pancreas.

Between one and four cases of insulinoma occur per million people per year, and 90% of these tumors are benign. They occur mostly between the ages of 50 and 60 and affect men and women equally. Less than three cases of gastrinoma per million people are diagnosed each year, but it is the most common functional islet cell tumor in patients with multiple endocrine tumors, a condition known as multiple endocrine neoplasia (MEN) syndrome. Vipoma and glucagonoma are even rarer and they occur more frequently in women. Somatostatinoma is exceedingly uncommon, and less than 100 cases have been reported worldwide. Nonfunctional islet cell cancers account for approximately one-third of all cancers of the endocrine pancreas, and the majority of these are malignant.

Causes and symptoms

There are no known causes of islet cell cancer, but a small percentage of cases occur due to hereditary syndromes such as MEN. This is a condition that frequently causes more than one tumor in several endocrine glands, such as the parathyroid and pituitary, in addition to the islet cells of the pancreas. Twenty-five percent of gastrinomas and less than 10% of insulinomas occur in MEN patients. Von Hippel-Lindau (VHL) syndrome is another genetic disorder that causes multiple tumors, and 10-15% of VHL patients will develop islet cell cancer.

Symptoms vary among the different islet cell cancer types. Insulinoma causes repeated episodes of hypoglycemia, sweating, and tremors, while patients with gastrinoma have inflammation of the esophagus, epigastric pain, multiple ulcers, and possibly diarrhea. Symptoms of glucagonoma include a distinctive skin rash, inflammation of the stomach, glucose intolerance, weight loss, weakness, and anemia (less common). Patients with vipoma have episodes of profuse, watery diarrhea, even after fasting. Somatostatinoma causes mild diabetes, diarrhea/steatorrhea (fatty stools), weight loss, and gallbladder disease. Non-functional endocrine tumors frequently produce the same symptoms as cancer of the exocrine pancreas such as abdominal pain, jaundice, and weight loss.

Diagnosis

A thorough physical exam is usually performed when a patient presents with the above symptoms, however, functional endocrine tumors of the pancreas tend to be small and are not detected by palpating the abdomen. Once other illnesses such as infection are ruled out, the doctor will order a series of blood and urine tests. The functional endocrine tumors can be identified through increased levels of hormone in the bloodstream.

Functional endocrine tumors can occur in multiple sites in the pancreas and are often small (less than 1 cm), making them difficult to diagnose. Non-functional tumors tend to be larger, which makes them difficult to distinguish from tumors of the exocrine pancreas. Methods such as computed tomography (CT) scan and magnetic resonance imaging (MRI) are used to take pictures of the internal organs and allow the doctor to determine whether a tumor is present. Somatostatin receptor scintigraphy (trade name OctreoScan) is an imaging system used to localize endocrine tumors, especially gastrinomas and somatostatinomas. Endoscopic ultrasound (EUS) is a more sensitive technique that may be used if a CT scan fails to detect a tumor. Endocrine tumors usually have many blood vessels, so angiography may be useful in the doctor's assessment and staging of the tumor. Surgical exploration is sometimes necessary in order to locate very small tumors that occur in multiple sites. These techniques also help the doctor evaluate how far the tumor has spread. A biopsy can be taken to confirm diagnosis, but more often, doctors look at the size and local invasion of the tumor in order to plan a treatment strategy.

Treatment

Staging

The staging system for islet cell cancer is still evolving, but the tumors typically fall into three categories: cancers that arise in one location within the pancreas, cancers that arise in several locations within the pancreas, and cancers that have spread to nearby lymph nodes or to other organs in the body.

Surgery is the only curative method for islet cell cancers, and studies have shown that an aggressive surgical approach can improve survival and alleviate symptoms of the disease. As with most forms of cancer, the earlier it is diagnosed, the greater the chance for survival. With the exception of insulinoma, the majority of islet cell tumors are malignant at the time of diagnosis, and more than half are metastatic. However, surgery and chemotherapy have been shown to improve the outcome of patients even if they have metastatic disease. Surgery may include partial or total removal of the pancreas, and in patients with gastrinoma, the stomach may be removed as well. Streptozotocin, doxorubicin, and 5-fluorouracil (5-FU) are chemotherapeutic agents commonly used in the treatment of islet cell cancer. Patients may experience nausea and vomiting as well as kidney toxicity from streptozotocin, and bone marrow suppression from doxorubicin. Hormone therapy is used to relieve the symptoms of functional tumors by inhibiting excess hormone production. Other techniques may be used to block blood flow to the liver in an attempt to kill the cancer cells that have spread there. Abdominal pain, nausea, vomiting and fever may result from this type of treatment. Radiation has little if any role in the treatment of islet cell cancer.

Prognosis

Islet cell cancers overall have a more favorable prognosis than cancers of the exocrine pancreas, and the median survival from diagnosis is three and a half years. This is mainly due to their slow-growing nature. Insulinomas have a five-year survival rate of 80% and gastrinomas have 65%. When malignant, islet cell cancers do not generally respond well to chemotherapy, and the treatment is mainly palliative. Most patients with metastasis do not survive five years. Islet cell cancer tends to spread to the surrounding lymph nodes, stomach, small intestine, and liver.

Prevention

There are no known risk factors associated with sporadic islet cell cancer. Therefore, it is not clear how to prevent its occurrence. Individuals with MEN syndrome or VHL, however, have a genetic predisposition to developing islet cell cancer and should be screened regularly in an effort to catch the disease early.

Resources

PERIODICALS

Anderson, M.A., et. al. "Endoscopic Ultrasound is Highly Accurate and Directs Management of Patients With Neuroendocrine Tumors of the Pancreas." American Journal of Gastroenterology 95, no. 9 (September 2000): 2271-7.

Hellman, Per, et. al. "Surgical Strategy for Large or Malignant Endocrine Pancreatic Tumors." World Journal of Surgery 24 (2000): 1353-60.

ORGANIZATIONS

National Cancer Institute. 9000 Rockville Pike, Bldg. 31, Rm.10A16, Bethesda, MD, 20892. (800) 422-6237. 〈http://www.nci.nih.gov〉.

National Familial Pancreas Tumor Registry. The Johns Hopkins Hospital. 600 North Wolfe St., Baltimore, MD 21287-6417. (410) 377-7450.

National Organization for Rare Disorders. 100 Route 37, PO Box 8923, New Fairfield, CT 06812. (203) 746-6518. 〈http://www.nord-rdb.com/∼orphan〉.

OTHER

"Islet Cell Carcinoma." CancerNetPDQ May 2001. [cited July 19, 2001]. 〈http://www.cancernet.nci.nih.gov〉.

Pancreatic Cancer Home Page. Johns Hopkins Medical Institutions. July 19, 2001. 〈http://www.path.jhu.edu/pancreas〉.

KEY TERMS

Adenocarcinoma— A malignant tumor that arises within the tissues of a gland and retains its glandular structure.

Angiography— Diagnostic technique used to study blood vessels in a tumor.

Biopsy— Removal and microscopic examination of cells to determine whether they are cancerous.

Chemotherapy— Drug treatment administered to kill cancerous cells.

Endocrine— Refers to glands that secrete hormones circulated in the bloodstream.

Endoscopic ultrasonography (EUS)— Diagnostic imaging technique where an ultrasound probe is inserted down a patient's throat to determine if a tumor is present.

Gastrinoma— Tumor that arises from the gastrinproducing cells in the pancreas.

Insulinoma— Tumor that arises from the insulin-producing cells in the pancreas.

Islets of Langerhans— Clusters of cells in the pancreas that make up the endocrine tissue.

Pancreatic cancer, endocrine

Definition

Endocrine pancreatic cancer is a disease in which cancerous cells originate within the tissues of the pancreas that produce hormones.

Description

The pancreas is a six-to eight-inch long, slipper-shaped gland located in the abdomen. It lies behind the stomach, within a loop formed by the small intestine. Other nearby organs include the gallbladder, spleen, and liver. The pancreas has a wide end (head), a narrow end (tail), and a middle section (body). A healthy pancreas is important for normal food digestion and plays a critical role in the body's metabolic processes. The pancreas has two main functions, each performed by distinct types of tissue. The exocrine tissue secretes fluids into the other organs of the digestive system, while the endocrine tissue secretes substances that are circulated in the bloodstream. The exocrine pancreas makes up the vast majority of the gland; it produces pancreatic juices containing enzymes that help break down proteins and fatty food. The endocrine tissue of the pancreas makes up only 2% of the gland's total mass. It consists of small patches of cells that produce hormones (like insulin) that control how the body stores and uses nutrients. These patches are called islets (islands) of Langerhans or islet cells and are interspersed evenly throughout the pancreas. Each islet contains approximately 1, 000 endocrine cells and a dense network of capillaries (tiny blood vessels), which allows immediate entry of hormones into the circulatory system.

Pancreatic tumors are classified as either exocrine or endocrine tumors depending on which type of tissue they arise from within the gland. Endocrine tumors of the pancreas are very rare, accounting for only 5% of all pancreatic cancers. The majority of endocrine pancreatic tumors are functional adenocarcinomas that overproduce a specific hormone. There are several types of islet cells and each produces its own hormone or peptide (small protein molecule). Functional endocrine tumors are named after the hormone they secrete. Insulinoma is the most common tumor of the endocrine pancreas. Patients with this disease usually develop hypoglycemia due to increased insulin production that leads to abnormally low blood sugar levels. Gastrinoma, a disease in which gastrin (hormone which stimulates stomach acid production) is overproduced, causes multiple ulcers in the upper gastrointestinal (GI) tract. Gastrinoma was first described in patients with a rare form of severe peptic ulcer disease known as Zollinger-Ellison syndrome (ZES). The less common glucagonoma causes mild diabetes due to excess glucagon (hormone which stimulates glucose production) secretion. Other rare islet cell tumors include vipoma (vasoactive intestinal peptide) and somatostatinoma. Nonfunctional pancreatic endocrine tumors are not associated with an excess production of any hormone and can be difficult to distinguish from exocrine pancreatic cancer. Cancers of the endocrine pancreas are relatively slow-growing compared to the more common ductal adenocarcinomas of the exocrine pancreas.

Demographics

Between one and four cases of insulinoma occur per million people per year, and 90% of these tumors are benign. They occur mostly between the ages of 50 and 60 and affect men and women equally. Less than three cases of gastrinoma per million people are diagnosed each year, but it is the most common functional islet cell tumor in patients with multiple endocrine tumors, a condition known as multiple endocrine neoplasia (MEN) syndrome . Vipoma and glucagonoma are even rarer and they occur more frequently in women. Somatostatinoma is exceedingly uncommon, and less than 100 cases have been reported worldwide. Nonfunctional islet cell cancers account for approximately one-third of all cancers of the endocrine pancreas, and the majority of these are malignant.

Causes and symptoms

There are no known causes of islet cell cancer, but a small percentage of cases occur due to hereditary syndromes such as MEN. This is a condition that frequently causes more than one tumor in several endocrine glands, such as the parathyroid and pituitary, in addition to the islet cells of the pancreas. Twenty-five percent of gastrinomas and less than 10% of insulinomas occur in MEN patients. Von Hippel-Lindau (VHL) syndrome is another genetic disorder that causes multiple tumors, and 10% to 15% of VHL patients will develop islet cell cancer.

Symptoms vary among the different islet cell cancer types. Insulinoma causes repeated episodes of hypoglycemia, sweating, and tremors, while patients with gastrinoma have inflammation of the esophagus, epigastric pain, multiple ulcers, and possibly diarrhea . Symptoms of glucagonoma include a distinctive skin rash, inflammation of the stomach, glucose intolerance, weight loss , weakness, and anemia (less common). Patients with vipoma have episodes of profuse, watery diarrhea, even after fasting. Somatostatinoma causes mild diabetes, diarrhea/steatorrhea (fatty stools), weight loss, and gallbladder disease. Nonfunctional endocrine tumors frequently produce the same symptoms as cancer of the exocrine pancreas such as abdominal pain, jaundice, and weight loss.

Diagnosis

A thorough physical exam is usually performed when a patient presents with the above symptoms; however, functional endocrine tumors of the pancreas tend to be small and are not detected by palpating the abdomen. Once other illnesses such as infection are ruled out, the doctor will order a series of blood and urine tests. The functional endocrine tumors can be identified through increased levels of hormone in the bloodstream.

Functional endocrine tumors can occur in multiple sites in the pancreas and are often small (less than 1 cm), making them difficult to diagnose. Nonfunctional tumors tend to be larger, which makes them difficult to distinguish from tumors of the exocrine pancreas. Methods such as computed tomography (CT) scan and magnetic resonance imaging (MRI) are used to take pictures of the internal organs and allow the doctor to determine whether a tumor is present. Somatostatin receptor scintigraphy (trade name OctreoScan) is an imaging system used to localize endocrine tumors, especially gastrinomas and somatostatinomas. Endoscopic ultrasound (EUS) is a more sensitive technique that may be used if a CT scan fails to detect a tumor. Endocrine tumors usually have many blood vessels, so angiography may be useful in the doctor's assessment and staging of the tumor. Surgical exploration is sometimes necessary in order to locate very small tumors that occur in multiple sites. These techniques also help the doctor evaluate how far the tumor has spread. A biopsy can be taken to confirm diagnosis, but more often, doctors look at the size and local invasion of the tumor in order to plan a treatment strategy.

Treatment team

Patients with islet cell cancer are cared for by a number of specialists from different disciplines. Medical oncologists, gastroenterologists, radiologists, and surgeons all interact with the patient to develop an appropriate treatment plan. Endocrinologists play an important role in helping patients with diabetes maintain steady blood sugar levels. Much of the treatment of islet cell cancer focuses on relieving symptoms of the tumor through medication that inhibits hormone overproduction. It is best for patients to work with doctors who are experienced in treating this rare form of cancer.

Clinical staging, treatments, and prognosis

Staging

The staging system for islet cell cancer is still evolving, but the tumors typically fall into three categories: cancers that arise in one location within the pancreas, cancers that arise in several locations within the pancreas, and cancers that have spread to nearby lymph nodes or to other organs in the body.

Treatments

Surgery is the only curative method for islet cell cancers, and studies have shown that an aggressive surgical approach can improve survival and alleviate symptoms of the disease. As with most forms of cancer, the earlier it is diagnosed, the greater the chance for survival. With the exception of insulinoma, the majority of islet cell tumors are malignant at the time of diagnosis, and more than half are metastatic. However, surgery and chemotherapy have been shown to improve the outcome of patients even if they have metastatic disease. Surgery may include partial or total removal of the pancreas, and in patients with gastrinoma, the stomach may be removed as well. Streptozocin , doxorubicin , and fluorouracil (5-FU) are chemotherapeutic agents commonly used in the treatment of islet cell cancer. Patients may experience nausea and vomiting as well as kidney toxicity from streptozocin, and bone marrow suppression from doxorubicin. Hormone therapy is used to relieve the symptoms of functional tumors by inhibiting excess hormone production. Other techniques may be used to block blood flow to the liver in an attempt to kill the cancer cells that have spread there. Abdominal pain, nausea, vomiting and fever may result from this type of treatment. Radiation has little if any role in the treatment of islet cell cancer.

Prognosis

Islet cell cancers overall have a more favorable prognosis than cancers of the exocrine pancreas, and the median survival from diagnosis is three and half years. This is mainly due to their slow-growing nature. Insulinomas have a five-year survival rate of 80% and gastrinomas have 65%. When malignant, islet cell cancers do not generally respond well to chemotherapy, and the treatment is mainly palliative. Most patients with metastasis do not survive five years. Islet cell cancer tends to spread to the surrounding lymph nodes, stomach, small intestine, and liver.

Coping with cancer treatment

Patients should discuss with their doctors any side effects they experience from treatment. Many drugs are available to relieve nausea and vomiting associated with cancer treatments and for combating fatigue . Insulin may be prescribed if patients develop diabetes as a result of partial or total removal of their pancreas. Special diets or fluids may be recommended if patients have more than one digestive organ removed. These patients may require intravenous feeding after surgery until they recover.

Clinical trials

Because this is such a rare disease, relatively few clinical trials are available to people with islet cell cancer. Most are investigating the efficacy of new chemotherapeutic drugs or combinations of drugs and biological therapies. R115777 is an agent being tested in combination with trastuzumab (Herceptin) for patients with advanced or metastatic adenocarcinoma. Two new drugs that are antineoplastons, A10 and AS2-1, are being examined together as a treatment regimen for patients with metastatic or incurable neuroendocrine tumors . Patients should ask their doctors whether they qualify for these or other clinical trials.

Prevention

There are no known risk factors associated with sporadic islet cell cancer. Therefore, it is not clear how to prevent its occurrence. Individuals with MEN syndrome or VHL, however, have a genetic predisposition to developing islet cell cancer should be screened regularly in an effort to catch the disease early.

Special concerns

Many patients find it helpful to join support groups after being diagnosed with cancer. Discussing the condition with others who are experiencing a similar situation may help to relieve anxiety and depression , which are often associated with cancer and its treatment. Medication may also be prescribed to alleviate depression. Patients should learn as much as they can about their illness and find out what their treatment options are. It is important for patients to remember that each cancer has unique characteristics and responds differently to treatment depending on those characteristics.

See Also Carcinoid tumors, gastrointestinal; Chemoembolization; Complementary cancer therapies; Endocrine system tumors; Familial cancer syndromes; Pancreatic cancer, exocrine; Upper gastrointestinal endoscopy

Resources

BOOKS

Beger, Hans G., et al., ed. The Pancreas. Oxford: Blackwell Science Ltd., 1998.

Dollinger, Malin, et al. Everyone's Guide to Cancer Therapy. Kansas City: Andrews McMeel, 1997.

Neoptolemos, John P., and Nicholas R. Lemoine. Pancreatic Cancer: Molecular and Clinical Advances. Oxford: Blackwell Science Ltd., 1996.

PERIODICALS

Anderson, M.A., et. al. "Endoscopic Ultrasound is Highly Accurate and Directs Management of Patients With Neuroendocrine Tumors of the Pancreas." American Journal of Gastroenterology 95, no. 9 (September 2000): 2271-7.

Hellman, Per, et. al. "Surgical Strategy for Large or Malignant Endocrine Pancreatic Tumors." World Journal of Surgery 24 (2000): 1353-60.

ORGANIZATIONS

National Cancer Institute. 9000 Rockville Pike, Bldg.31, Rm.10A16, Bethesda, MD, 20892 (800) 422-6237. <http://www.nci.nih.gov>.

National Familial Pancreas Tumor Registry. The Johns Hopkins Hospital. 600 North Wolfe St., Baltimore, MD 21287-6417. (410) 377-7450

National Organization for Rare Disorders. 100 Route 37, PO Box 8923. New Fairfield, CT 06812. (203) 746-6518. <http://www.nord-rdb.com/~orphan>

OTHER

"Islet Cell Carcinoma." CancerNet PDQ May 2001. 19 July 2001 <http://www.cancernet.nci.nih.gov>.

Pancreatic Cancer Home Page Johns Hopkins Medical Institu tions. 19 July 2001 <http://www.path.jhu.edu/pancreas>

Elizabeth Pulcini, M.Sc.

KEY TERMS

Adenocarcinoma

—A malignant tumor that arises within the tissues of a gland and retains its glandular structure.

Angiography

—Diagnostic technique used to study blood vessels in a tumor.

Biopsy

—Removal and microscopic examination of cells to determine whether they are cancerous.

Chemotherapy

— Drug treatment administered to kill cancerous cells.

Endocrine

—Refers to glands that secrete hormones circulated in the bloodstream.

Endoscopic Ultrasonography (EUS)

—Diagnostic imaging technique where an ultrasound probe is inserted down a patient's throat to determine if a tumor is present.

Gastrinoma

—Tumor that arises from the gastrin-producing cells in the pancreas.

Insulinoma

—Tumor that arises from the insulin-producing cells in the pancreas.

Islets of Langerhans

—Clusters of cells in pancreas that make up the endocrine tissue.