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    Pancreas Cancer
    Diagnosis and Treatment Overview

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    Pancreas Cancer Overview

    The pancreas (in yellow) is located behind the stomach and underneath the liverPancreatic cancer - cancer in the gland that produces digestive enzymes and hormones, including insulin - affects more than 37,000 Americans each year, the majority of whom are 65 or older. Smoking, diabetes, age, alcohol, chronic pancreatitis, familial pancreatitis and genetic factors, as well as dietary habits, are common risk factors associated with pancreatic cancer.

    Tumors in the pancreas are classified as exocrine or endocrine tumors. Exocrine tumors (known as adenocarcinoma) originate in the lining of the pancreatic ducts and comprise the majority (80 – 90%) of all pancreatic tumors. Endocrine tumors, which begin in the islet cells of the pancreas, account for 10-20% of cases. At California Pacific, our team has expertise in treatment of both.

    Symptoms such as unintentional weight loss, jaundice, new onset of diabetes, or abdominal pain may raise suspicion for pancreatic cancer. However, detecting a pancreatic tumor and establishing a diagnosis can be difficult, due to the gland’s location deep within the abdomen.

    Diagnostic Tools and Staging for Pancreas Cancer

    Technological advances have changed the approach to evaluating patients with suspected pancreatic tumor(s). State-of-the-art imaging technology now allows physicians to better answer two key questions in the evaluation of patients with suspected pancreatic tumors:

    1. Is there really a tumor present?

    2. If a tumor is present, can it be removed (and thereby potentially cured) by surgical removal?


    Algorithm to approaching patients with suspected pancreatic cancer

    If pancreas cancer suspected, perform high-quality CT or MRI (pancreatic protocol). If tumor detected, perform EUS for tumor staging and FNA for tissue diagnosis. If no tumor detected, perform EUS (comfirms presence or absence of tumor).
    Because of the pancreas’ position below the stomach, non-invasive imaging studies are imperative to provide visualization of the pancreas and possible tumor(s).

    Non-Invasive Imaging

    The first step in evaluating an individual with suspected pancreatic cancer is to determine whether a cancer is truly present. Noninvasive imaging studies such as a computed tomography (CT) or magnetic resonance imaging (MRI) are initial diagnostic tests of choice. Specific CT imaging protocols and MRI sequences that optimize visualization of the pancreas should be used.






    Endoscopic Ultrasound

    Physicians guide the endoscope through the stomach to provide visualization of a pancreas tumor(s).Although CT and MRI show many pancreatic cancers, some can be missed, especially when a tumor is small. If one highly suspects the presence of disease, endoscopic ultrasound (EUS) is essential.

    EUS is a relatively new endoscopic procedure that uses an ultrasound probe at the tip of an endoscope to provide high-quality, detailed images of structures in and around the gastrointestinal tract. During upper endoscopy, the echoendoscope is placed in the stomach and duodenum to obtain detailed images of the entire pancreas and adjacent structures. Tumors are more accurately detected - or excluded - by EUS as compared to CT or MRI.

    EUS also provides a means for tissue diagnosis. Under real-time EUS guidance, a fine needle aspiration (FNA) biopsy can be performed to provide a cytopathologic sample. EUS is a more accurate and safer method to perform biopsies of pancreatic tumors than other methods, including endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous image-guided biopsies.

    Tumor Staging

    Once the presence of a pancreatic tumor is confirmed, the next major step is to determine surgical resectability. Assessing the spread of the tumor is referred to as tumor staging. Accurate tumor staging is important as it guides the appropriate therapy for an individual with pancreatic cancer. The benefits of surgery to remove and potentially cure a cancer must be balanced with avoiding unnecessary surgical exploration in those with advanced tumors.

    A combination of diagnostic tests provides the best assessment of pancreatic tumor stage. These include a noninvasive imaging test (CT or MRI) and EUS. A high-quality, pancreatic protocol CT or MRI excludes distant tumor spread (especially liver metastases), and provides information on the local extent of the tumor, including spread to adjacent structures.

    EUS offers a highly useful complementary test. Tumor extension into vascular structures and tumor involvement of adjacent lymph nodes is well-visualized with EUS. Occasionally, EUS will also identify and allow biopsy of unsuspected, occult metastases. The combination of EUS with CT or MRI provides more accurate assessment of tumor stage than either diagnostic tool alone.

    The staging classification by the American Joint Committee on Cancer (AJCC) classifies the spread of pancreatic cancer as follows:

    Pancreas sections used in defining tumor(s) location: Head, neck, body & tail. Pancreatic duct runs through all sections.
    • T2: tumor invasion of the bile duct

    • T3: tumor invasion of the portal vein, superior mesenteric vein and/or splenic vein

    • T4: tumor invasion of the superior mesenteric artery and/or celiac axis


    Treatment for Pancreas Cancer

    Surgical Treatment

    Pancreas anatomy prior to a Whipple procedure. The blue represents structures that are removed during surgery.Whipple Procedure - When cancers occur in the head portion of the pancreas, surgeons can potentially remove the entire cancer with a Whipple procedure. About 20% of pancreatic cancer cases require a Whipple procedure, or resection of the pancreas head and neck, duodenum and distal bile duct with subsequent reconstruction. At California Pacific Medical Center, surgeons perform more than 50 Whipple procedures annually. In most cases, California Pacific’s surgeons perform a Pyloric Sparing Whipple, a relatively new technique which leaves intact the stomach and its opening into the intestine.








    Illustration of a Pyloric Sparing Whipple procedure in which the pancreas head and neck, duodenum, gallbladder and bile duct are resected, followed by one continuous bowel limb for reconstruction.       Illustration of a Pyloric Sparing Whipple procedure using R & Y bowel reconstruction.

    In a Distal Pancreatectomy procedure with Splenectomy, the tail of the pancreas containing the tumor and the spleen are removed.Distal Pancreatectomy - Cancer in the neck or body of the pancreas (which is less frequent) would be treated with distal removal of the pancreas and splenectomy. Cancer that invades a portion of the liver vein (portal vein) or its tributaries could still be removed surgically and a piece of vein from the neck or leg can be used for reconstruction. However, cancer that invades the artery is not resectable.



    Endoscopic Therapy

    Endoscopic procedures play an important role in managing patients with pancreatic cancer. Tumors that are located in the head of the pancreas often cause blockage of the bile duct and lead to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) is a useful technique to relieve the biliary obstruction. During ERCP a small catheter is inserted into the bile duct through an endoscope and contrast media is injected to provide detailed radiographic images of the biliary system. Either temporary plastic stents (for resectable tumors) or more durable self-expandable metallic stents (for inoperable cancers) can be placed endoscopically across the site of obstruction to provide biliary drainage.

    Systemic Therapy

    Chemotherapy plays an important role in the overall management of pancreatic cancer. At California Pacific, a multidisciplinary team of medical oncologists, hepatologists and/or gastroenterologists, and interventional endoscopists work together with pancreatic cancer patients, evaluating an individual’s ability to tolerate surgery, endoscopic therapy, and/or chemotherapy.

    Chemotherapy generally refers to pharmacologic agents, whether they are oral, intramuscular or intravenous, with activity against pancreatic cancer cells. For individuals who undergo surgical resection of their pancreatic cancer, adjuvant chemotherapy has been shown to improve survival according to data from several recent clinical trials. Adjuvant chemotherapy is given for a defined time period following surgery; for some patients a brief period of post-operative radiation therapy is also recommended. Upon completion of adjuvant therapy, patients are considered in remission and undergo routine surveillance.

    For individuals who relapse, or those whose disease is considered unresectable due to locally advanced or metastatic cancer, chemotherapy is the prime modality.

    Clinical Trials

    Due to California Pacific’s large volume of pancreatic cancer patients, we are able to offer clinical trials with novel anti-cancer agents. Because pancreatic cancer is considered a poor prognosis cancer, many of our investigators seek to improve upon existing chemotherapeutic agents. In collaboration with California Pacific’s Research Institute, the Medical Center maintains an active clinical research group. We are frequently the only center in Northern California to have access to exciting and novel agents via clinical trials available for individuals with pancreatic cancer. Participation in clinical research is always voluntary.

    Sadly, many individuals who undergo surgical resection will relapse and many patients present with locally advanced disease that is not amenable to surgical resection. For these patients, clinical trials with novel agents may offer enhanced efficacy over standard chemotherapy agents. At any one time patients with advanced and/or unresectable disease may have multiple clinical trials available.

    Why Choose Us

    Hepatobiliary and pancreas diseases - disorders of the liver, bile ducts, gallbladder and pancreas - form a complex set of medical problems whose treatment often requires equally challenging surgical procedures. At California Pacific Medical Center, we have been leaders in hepatobiliary and pancreas surgery since the founding of our liver transplant program in 1988. Our doctors are closely involved in clinical research and surgical innovation. Annually, our physicians provide care to some 4,000 hepatobiliary and pancreas patients, both in San Francisco and at our network of outreach sites in California and Nevada.

    For patients requiring hospitalization, we have a dedicated critical care liver unit, hospitalists who specialize in hepatobiliary disease, physician assistants, on-call anesthesia staff and a specialized O.R. nursing team.

    Genetic Risk Assessment

    The Cancer Genetic Risk Assessment Program at California Pacific offers individuals with a personal or family history pancreatic cancer the opportunity to learn more about the genetic nature of their disease and whether they may be predisposed to other cancers which they could monitor. Individuals meet with our genetic counselor during which an evaluation of one’s medical and family history is performed, as well as a detailed risk assessment and genetic education. If appropriate, genetic testing may be offered and facilitated by the genetic counselor. A genetic risk assessment may assist in medical management decisions such as aggressive cancer screening and preventive measures. For more information, call the Cancer Genetic Risk Assessment Program at 415-6005961 or visit www.cpmc.org/services/cancer/patient/cancer-genetic-test.html.

    About California Pacific Medical Center

    California Pacific Medical Center, part of the Sutter Health networkOpens new window, offers specialized care in liver and hepatobiliary and pancreas disease. Our program is based in San Francisco and has outreach locations throughout Northern California and Nevada.

    San Francisco Center for Liver Disease
    California Pacific Medical Center
    2340 Clay Street, 4th Floor
    San Francisco, CA 94115

    Hepatobiliary Surgeons
    Tel: 415-600–1020

    Interventional Endoscopy Service
    Tel: 415-600-1151
    Fax: 415-600-1416

    Oncologists
    Tel: 415-923-3012
    Fax: 415-928-4840

    For referrals and patient transfer, contact California Pacific’s Specialty Referral Program
    Tel: 1-888-637–2762
    Fax: 1-415-600–2955