The pancreas
The pancreas is an organ of the digestive system, which breaks down food so it can be absorbed and used by body cells. It is a thin, lumpy gland about 13 cm long that lies between your stomach and spine. The pancreas is divided into several parts: the large rounded section is called the head of the pancreas, the middle part is known as the body, and the narrow part at the end is the tail.
A tube called the pancreatic duct connects the pancreas to the first part of the small bowel (small intestine). This section of the small bowel is known as the duodenum. Another tube called the common bile duct passes under the pancreas. This tube carries bile – a substance that helps to digest fats – from the liver and gall bladder to the small bowel.
The pancreas contains two types of glands: the exocrine glands and the endocrine glands.
Exocrine glands - produce juices called enzymes that help break down your food. These juices flow from the pancreas into your duodenum through the pancreatic duct. Most of the pancreas is made up of exocrine glands.
Endocrine cells - are scattered amongst the exocrine glands in small clusters called pancreatic islets (or islets of Langerhans). They release chemical messengers (hormones) that control the amount of sugar in the blood. The hormone insulin decreases blood sugar levels, while the hormone glucagon increases blood sugar levels.
View image of the position of the pancreas.
Types of pancreatic cancer
Pancreatic cancer usually occurs in the head of the pancreas where it may obstruct the bile duct and cause jaundice. It may also spread to nearby nerves and lymph nodes and may cause pain.
Exocrine tumours:
- The most common type of pancreatic cancer.
- Most common exocrine tumour, adenocarcinoma, begins in the lining of the pancreatic duct.
- Adenocarcinomas make up 95% of all exocrine pancreatic cancers.
- Other types of exocrine pancreatic cancers include: adenosquamous carcinomas, squamous cell carcinomas and giant cell carcinomas.
Endocrine tumours:
- Tumours of the endocrine are uncommon.
- Known as islet tumours.
- Broken into subtypes depending on the type of hormone they produce: islet tumours that produce insulin are known as insulinomas; tumours that make glucogon are known as glucagonomas.
- Most islet tumours are benign.
How common is it?
- About 686 people are diagnosed with pancreatic cancer in NSW each year.
- 13th most common cancer in NSW.
Diagnosis
Blood tests
Blood counts determine if blood cells are normal in number and appearance.
Results show how well organs are working.
Imaging tests
Ultrasound
- Scan that uses soundwaves to build up pictures of the body.
- Gel is spread over the abdomen and a paddle-shaped device is moved over the area for a few minutes.
- Painless and non-invasive.
- Takes a few minutes.
CT (computerised tomography scan)
- Uses x-ray beams to compile many pictures of the body.
- You may have an injection of a special dye into your veins before the scan.
- You will be asked to lie still on a table while the CT scanner, which is large and round like a doughnut, slowly moves around you.
- Painless.
- Takes 10-30 minutes.
MRI (magnetic resonance imaging) scan
- Uses a combination of magnetism and radio waves to build up detailed cross-section pictures of the body.
- A special dye may be injected into your veins before the scan.
- You will lie on a couch in a metal cylinder – a large magnet – that is open at both ends.
- Painless.
- Takes about one hour.
Endoscopy and ERCP
- An endoscope is a thin, flexible tube with a light and camera that is passed down the throat into the digestive system.
- The doctor can inject dye directly through the tube into the pancreatic duct and bile duct so images of the organs appear on x-ray pictures called cholangiograms. This is part of an endoscopic retrograde cholangio-pancreatography (ERCP).
- Shows blockages and inflammation in these ducts.
- You can’t drink or eat before the endoscopy or ERCP.
- A sedative or anaesthetic is given.
- The doctor may take a tissue or fluid sample (biopsy).
- Risks include infection, bleeding and pancreatitis.
Endoscopic ultrasound (EUS)
- An ultrasound that is performed through a tube called an endoscope. An ultrasound transducer is attached to the end of the tube.
- The endoscope is passed through the mouth and stomach, and into the duodenum (small bowel).
- Good at locating small tumours in the pancreas.
PET (positron emission tomography) scan
- A specialised imaging test that is not common and is still undergoing evaluation for its use in pancreatic cancer.
- You are given a radioactive glucose solution that circulates in your body for 30 to 90 minutes.
- Your body is scanned for high levels of radioactive glucose.
- Takes several hours to prepare for and undergo the scan.
Tissue sampling
Fine needle biopsy
- Removing a sample of cells or tissue for examination.
- A fine needle is used to take the sample, and an ultrasound or CT scan may be used to guide the needle.
- Done during an endoscopy, ERCP or endoscopic ultrasound.
- A sedative or anaesthetic is given.
Laparoscopy
- Sometimes called keyhole surgery – the operation is done through a small cut near the bellybutton.
- A laparoscope is an instrument used to look inside the abdomen.
- You will be asked not to eat or drink for eight hours beforehand.
- You will have a general anaesthetic.
- The doctor may take a tissue or fluid sample (biopsy).
- You will have stitches.
- Side effects include pain, infection or damage to internal organs.
- There is a small risk of infection or damage to an organ. The doctor will explain the risks to you.
Staging
Staging tells the doctor how far the cancer has spread. This helps your health care team decide what treatment is best for you.
- Stage I – Cancer is found only in the pancreas, and has not spread to any organs next to the pancreas. This is called early-stage disease.
- Stage II – Cancer has spread to lymph nodes near the pancreas or is large but has not spread to nearby organs.
- Stage III – Cancer has grown into nearby large blood vessels or organs such as the stomach, spleen or large bowel. There may or may not be cancer in the lymph nodes.
- Stage IV – The cancer has spread to other organs, such as the liver or lungs or lining of the abdomen. Your doctor may call this advanced cancer.
Prognosis
Prognosis means the expected outcome of a disease.
The sooner pancreatic cancer is diagnosed, the better the prognosis. This is because the cancer may not have spread beyond the pancreas and treatment can start earlier. However, pancreatic cancer is usually not found until it is advanced because symptoms are often vague or go unnoticed. This makes a cure is more difficult.
You will need to discuss your prognosis with your doctor, but it is not possible for any doctor to give you a 100% accurate prediction on the course of the illness. The type of cancer, test results, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and your medical history are all important factors in assessing your prognosis.
Which health professionals will I see?
Your GP will arrange the first tests to check out your symptoms. If these tests do not rule out cancer, you will usually be referred to a specialist who will arrange further tests and advise you about treatment options.
Health professionals who may care for you include:
- gastroenterologist – involved in diagnosis of pancreatic cancer and treatment of bile duct obstruction
- upper gastrointestinal surgeon – responsible for surgery to the oesophagus, stomach, small intestine, gall bladder, liver, pancreas and spleen
- medical oncologist – prescribes and coordinates chemotherapy
- radiation oncologist – prescribes and coordinates radiotherapy
- endocrinologist – involved in diagnosis and treatment of hormone disorders and diabetes
- nurses – support and assist you through all stages of your cancer
- dietician – recommends the best eating plan to follow while you are in treatment and recovering
- social worker, physiotherapist and occupational therapist – link you to support services and help you to get back to normal activities.
Surgery
Surgery offers the best chance of cure for patients who have early-stage disease (cancer has not spread beyond the pancreas) and who are in reasonably good health (apart from the cancer).
Most common operation is Whipple's surgery or the Whipple operation.
Whipple’s surgery
This major operation removes:
- part of the pancreas
- the first part of the small bowel (duodenum)
- part of the stomach
- the gall bladder and part of the bile duct.
The surgeon reconnects the remainder of the pancreas, bile duct and stomach to different sections of the small bowel so the digestive tract keeps working.
View an image of Whipple's surgery.
After the operation
- Hospital stay of 10–14 days.
- Pain and discomfort for several days after the operation.
- You will be given painkillers and an intravenous infusion (drip) to replace your body’s fluids until you are able to drink and eat again after a few days.
- Some people need to take tablets to help digest fat and proteins, and some people develop diabetes, which may require insulin therapy.
Other surgical options
- Double bypass is surgery to bypass blockages in the bile duct and any blockage of the stomach outlet.
- This is palliative surgery to relieve symptoms and make you more comfortable.
- A piece of your bowel is joined to the bile duct or gall bladder to take the bile around the blockage.
- Hospital stay of 7–10 days.
Other treatment types