Cancer of the Pancreas

Pancreatic cancer occurs when malignant (cancerous) cells form in the the pancreas. This vital organ, situated behind the stomach, has two primary functions: producing digestive enzymes and hormones, such as insulin, which regulates blood sugar levels. The cancer’s aggressive nature often leads to late-stage diagnosis, contributing to its high mortality rate.

Types

The main types of pancreatic cancer include:

Pancreatic Adenocarcinoma

Accounts for about 90% of cases. It arises from the exocrine cells, which produce digestive enzymes.

Pancreatic Neuroendocrine Tumors (NETs)

These tumors develop from the hormone-producing cells and can be functioning (producing hormones) or non-functioning (not producing hormones). They are less common but can be less aggressive.

Pancreatic cystic neoplasms

Pancreatic cystic neoplasms, not all of which are malignant

Risk Factors

Several factors increase the likelihood of developing pancreatic cancer:

Age

Mostly in those above 65 years

Smoking

Tobacco use significantly raises the risk

Obesity

Excess body weight is associated with a higher risk

Family History & Genetic Factors

A family history of pancreatic cancer or hereditary conditions like BRCA mutations, Lynch syndrome, or familial pancreatitis can increase risk

Chronic Pancreatitis

Chronic Pancreatitis is linked to an increased risk of cancer

Symptoms

Early stages of pancreatic cancer often present few symptoms, making it difficult to diagnose. When symptoms do appear, they may include

Jaundice

Yellowing of the skin and eyes, sometimes with itching of the skin

Abdominal pain

Sometimes radiating to the back

Weight loss

Unexplained weight loss is common

Loss of appetite

Other symptoms

Other symptoms may include nausea, vomiting, clay-coloured stools or red / black stools or steatorrhea (fatty stools)

Diagnosis

If gallbladder cancer is suspected, your doctor may perform several tests, including:

Step 1

Simple blood tests ( Liver function tests or LFT ) and an ultrasound may raise the suspicion

Step 2

A good quality CT scan ( Triple phase CECT Upper abdomen – pancreas protocol ) combined with either a Chest CT or a PET scan is the main test needed to diagnose and stage pancreatic adenocarcinomas. A different kind of PET scan called DOTA-PET is used when one suspects that a patient may be suffering from pancreatic neuroendocrine tumours ( NETs )

Step 3

Other tests to complete the work-up include blood for CBC, urea, creatinine, sodium, potassium, HbA1c, TSH, PT/INR, virak markers , tumour markers like CA19-9, Chest X –ray, ECG and echocardiography.

Rarely some patients may need an endoscopic ultrasound (EUS) or a biopsy of the tumour before surgery.

NO PATIENT OF PANCREATIC CANCER SHOULD HAVE A ENDOSCOPIC STENT ( ERCP stent ) OR A BIOPSY till he / she has had a CT scan / PET scan and has been seen by a a specialist surgeon who is well trained and has expertise in performing the most radical operations for this kind of cancer. The surgeon must assess the patient after the CT / PET and has to take decisions about :

  • Need for biopsy
  • Need for ERCP and stenting by gastroenterologist, when rarely indicated
  • Whether the cancer can be takeout by surgery – operable or not

These can be very complicated decisions, but these must be taken before any treatment is started. 

Those pancreatic cancers that are advanced or have spread may need ERCP and stent placement followed by palliative chemotherapy , which unfortunately cannot cure the cancer.

Treatment Options

Treatment options for pancreatic cancer depend on the stage and location of the tumor, as well as the patient’s health.

Surgery for Pancreatic Cancer

Surgery is the most effective treatment for localized pancreatic cancer, particularly if the tumor is confined to the pancreas and surrounding tissues. The type of surgical procedure depends on the location, size, and stage of cancer. Here are the primary surgical options in detail:

Whipple’s operation (Pancreaticoduodenectomy)

Indication: Cancers in the head of the pancreas, or lower bile duct, ampulla or duodenum

Procedure: This radical surgery involves the removal of:

  • The head of the pancreas
  • The duodenum (the first part of the small intestine)
  • The gallbladder
  • A portion of the bile duct
  • Often a part of the stomach

Reconstruction: After removing these organs, the surgeons reconnect the remaining pancreas, bile duct, and stomach to the intestine ( jejunum ) to allow for digestive function.

Recovery: Patients typically stay in the hospital for about 7-10 days after surgery. 70 % patients have a smooth and uneventful recovery and are up and about within a few weeks. 30% patients have complications which may slow down the process of recovery, while upto 3-5% patients may actually die from the complications of the cancer surgery .

Distal Pancreatectomy – laparoscopic or robotic

Indication: For tumors located in the body or tail of the pancreas.

Procedure: Involves the removal of:

  • The body and tail of the pancreas
  • Sometimes, the spleen is removed as well, especially if the tumor is close to it

Postoperative Care

  • Monitoring: Patients are closely monitored in the hospital for complications such as leaks from the surgical connections.
  • Dietary Management: A gradual reintroduction of food is typically recommended, starting with a clear liquid diet and progressing to solid foods.
  • Long-term Management: Patients will need regular follow-ups to monitor for any signs of recurrence and to manage any long-term effects of surgery, such as diabetes and enzyme replacement needs
  • Chemotherapy: Often the primary treatment, especially for advanced stages. Common regimens include FOLFIRINOX (a combination of drugs) or gemcitabine-based therapies.
  • Radiation Therapy: rarely required
  • Targeted Therapy: Newer therapies focus on specific genetic alterations in the tumor

Prognosis

Pancreatic adenocarcinoma has one of the lowest survival rates among cancers. The five-year survival rate is approximately 11%, largely due to late-stage diagnosis. However, early detection and timely surgery gives the best results!

Summary Points

  • Pancreatic adenocarcinoma is a formidable disease. However , radical surgery to remove the cancer and its surrounding areas gives the bet results.
  • DO NOT RUSH TO HAVE AN ENDOSCOPIC STENT OR A BIOPSY – it may cause more harm than benefit!.
  • The DECISION whether your pancreatic cancer can be removed by surgery ( operable or not ) is a very complicated decision that can only be taken by a specialist surgeon who is well trained and has expertise in performing the most radical operations for this kind of cancer. Too many pancreatic head cancers are presumed to be inoperable and sent for palliative chemotherapy only, with dismal results – many are actually operable and therefore curable.
  • Almost all patients will need chemotherapy after surgery to reduce the chances of the cancer coming back.
  • Pancreatic neuroendocrine tumours ( NETs) and cystic tumours of the pancreas have much better outcomes as compared to pancreatic adenocarcinoma

Pancreatic Cysts

Pancreatic cysts are fluid-filled sacs that form in the pancreas, the organ behind your stomach that helps with digestion and blood sugar control.

Some key points:

Types

They can be non-cancerous (benign) or precancerous/malignant. Common types include serous cystadenomas (usually benign), mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms (IPMNs), which can have cancer potential.

Symptoms

Many pancreatic cysts cause no symptoms and are found accidentally on scans. If symptoms appear, they might include abdominal pain, nausea, vomiting, or a feeling of fullness.

Causes

Some cysts form after pancreatitis (inflammation of the pancreas), while others are related to genetic conditions or occur without a clear reason.

Diagnosis

Imaging like CT scans, MRI, or endoscopic ultrasound helps detect and evaluate cysts.

Treatment

Depends on the cyst type — options range from monitoring with regular scans to surgical removal if there's a risk of cancer

Chronic Calcific Pancreatitis
/ Pancreatic Stone

This  is a long-term inflammation of the pancreas where calcium deposits (calcifications) form in the pancreas. Over time, the pancreas becomes scarred and hardened, losing its ability to function properly — both for digestion (exocrine function) and for blood sugar control (endocrine function).

Causes

  • Chronic alcohol consumption (most common worldwide)
  • Genetic factors (e.g., hereditary pancreatitis)
  • Autoimmune conditions
  • Tropical pancreatitis (seen in certain regions like southern India, Africa)
  • Obstructive causes (like tumors or strictures)
  • Idiopathic (sometimes no cause is found)

Pathophysiology

  • Repeated inflammation damages pancreatic ducts
  • Leads to obstruction and protein plug formation
  • Calcium deposits over these plugs → calcification
  • Progressive fibrosis (scarring) of pancreatic tissue → loss of function

Symptoms

  • Chronic, recurrent upper abdominal pain (can radiate to the back)
  • Malabsorption → weight loss, steatorrhea (fatty stools)
  • Diabetes mellitus (secondary to islet cell destruction)
  • Jaundice (if bile duct is compressed)

Diagnosis

Imaging tests

  • X-ray: May show pancreatic calcifications
  • CT scan: More detailed, shows calcifications, ductal changes
  • MRI/MRCP: For ductal and parenchymal evaluation.

Endoscopic Ultrasound (EUS)

Sensitive for early disease

Function tests

Assess exocrine insufficiency (e.g., fecal elastase)

Treatment

Lifestyle changes

Stop alcohol, stop smoking

Pain control

Often needs a stepwise approach from NSAIDs to opioids; nerve blocks if severe.

Enzyme supplementation

Pancreatic enzyme replacement therapy (PERT) for malabsorption.

Control diabetes

Insulin if needed.

Surgical or endoscopic interventions

If there’s ductal obstruction, pseudocysts, or severe pain.

When medical management (like pain control, enzyme supplements, and diet changes) isn’t enough, surgery might be considered.

The main surgery done for chronic calcific pancreatitis:

Frey Procedure
  • A combination where part of the pancreatic head is cored out and a drainage anastomosis is created.
  • Especially used when the disease is mainly in the head of the pancreas.

Complications to watch for

  • Pancreatic pseudocysts
  • Bile duct obstruction
  • Pancreatic cancer (risk increases)
  • Malnutrition