Pancreatic Diseases / Pancreatic Cancer

Pancreatic pseudocyst

Pancreatic pseudocyst occurs as a complication of liver trauma or acute pancreatitis, forming during the resolution phase of the acute pancreatitis episode and involves a continuity solution in the pancreatic ducts.

Signs and symptoms

Most pancreatic pseudocysts do not give symptoms. However, in their presence they may appear as a triad:
  • Pain in the upper abdominal (epigastric) floor, with or without radiation to the left shoulder
  • Dyspeptic syndrome
  • Pseudotumour/formation, palpable, well individualized, of elastic consistency
If symptoms worsen, they may occur:
  • Occlusive syndrome
  • Infectious syndrome
  • Pseudocyst rupture leading to ascites (fluid in the abdomen) or peritonitis
  • Bleeding (haemorrhage) inside the pseudocyst
  • Fistula (communication) between pseudocyst and a nearby organ

Establishing the diagnosis

– Blood tests – pancreatic enzymes may appear altered (amylase, lipase)
– Urinalysis – presence of amylase in urine (amylaseuria)

–
Imaging tests
 – abdominal ultrasound – non-invasive and atraumatic imaging method based on ultrasound, which involves visualization of intra-abdominal organs, with the possibility of visualizing a cystic formation
– Computed Tomography (CT) – produces a series of detailed images of certain regions of the body, these images are taken from different planes; contrast material is used to better highlight the region being explored; it provides details about the location of the pseudocyst, its size, its relationship to surrounding organs, etc., and is the method of choice

–
Colangio-RMN
 – imaging method using a magnetic field and radiofrequency pulses to visualize images of various organs and tissues of the human body; for better visualization, contrast material may also be used; provides superior data on the anatomy of the biliary and pancreatic tree

–
Endoscopic ultrasound
 – a method that combines ultrasound with endoscopy, the method allows visualization of the cystic formation, and its differentiation with a malignant tumor

Treatment

– Conservative/medical treatment (6 weeks) – under ultrasound surveillance and if the size of the pseudocyst is less than 6 cm, which involves: hygienic-dietary regimen, pain relievers (Algocalmin, Piafen, Paracetamol), antispasmodics (No-Spa), hydroelectrolyte rebalancing if needed, gastric antisecretors, pancreatic ferments to improve digestion, prophylactic antibiotic therapy, pancreatic secretion inhibitors
– Surgical treatment – if the size of the cyst is more than 6 cm and/or the patient is symptomatic, which involves internal drainage of the pancreatic pseudocyst by surgical approach (classic, laparoscopic, hybrid technique: laparoscopic assisted endoscopic)

As appropriate, endoscopic, echoendoscopic, percutaneous drainage may be indicated.

Pancreatic lithiasis/chronic pancreatic pseudotumor

Pancreatic lithiasis involves the presence of calculi in the pancreatic ducts inside the pancreas.
Chronic pancreatitis is a chronic inflammatory disease of the pancreas characterized by repetitive episodes of inflammation with necrosis and subsequent fibrosis of glandular tissue, progressively leading to destruction of the exocrine and endocrine parenchyma.

Signs and symptoms

It can manifest itself in repeated bouts of acute pancreatitis. Other signs and symptoms may include:
  • Continuous or interminable bar pain located in the upper abdominal (epigastric) floor, radiating to the back
  • Exocrine pancreatic insufficiency characterized by malabsorption, diarrhea, steatosis (stools that are lumpy, occur due to decreased ability of the pancreas to secrete enzymes for fat digestion, thus more fat ends up in the stool undigested, stools having a shiny, pungent odor, floating appearance)
  • Endocrine failure (onset of diabetes)

Establishing the diagnosis

– Blood tests – pancreatic enzymes may appear altered (amylase, lipase)
– Urinalysis – presence of amylase in urine (amylaseuria)
– Imaging tests – abdominal ultrasonography – non-invasive and atraumatic ultrasound-based imaging method involving visualization of the intra-abdominal organs, with the possibility of visualization of a cystic formation; may reveal abnormalities of the pancreatic ducts (calculi, stenosis, dilatation), parenchymal abnormalities (calcifications, pseudocysts)
– Computed tomography (CT) – produces a series of detailed images of certain regions of the body, these images are taken from different planes; contrast material is used to better highlight the region being explored; can reveal abnormalities of the pancreatic ducts (calculi, stenosis, dilatation), parenchymal abnormalities (calcifications, pseudocysts, pseudotumor appearance, suspicion of malignant process)

Treatment

  • Surgical treatment
in case of chronic pancreatitis with pancreatic lithiasis – pancreatic ductal stenosis prosthesis + pancreatic duct stone extraction, main bile duct prosthesis (after excluding neoplasia/ malignancy/ cancer)
  • Endoscopic treatment
In case of stenosis of the main bile duct, duodenum, in case of dilation of the main pancreatic duct (pancreatico-jejunal anastomosis – through which pancreatic juice is drained into the small intestine), in case of situations when endoscopic treatment is not effective.

Benign pancreatic tumours

Benign tumours are non-cancerous tumours that remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms by putting pressure on surrounding structures. Benign tumours of the pancreas are pancreatic endocrine tumours that are classified according to symptoms into secretory and non-secretory tumours. The most common types are insulinomas, gastrinomas, glucagonomas and somatostatinomas.

Signs and symptoms

Insulinoma – is a small tumour (less than 2 cm), 90% of cases are benign and originate from beta islet cells of the endocrine pancreas. As symptoms it is manifested by:
  • Weakness, headache, confusion, double vision (diplopia), seizures or even coma in advanced forms
  • Low blood glucose (hypoglycemia below 45 mg/dl)
  • Rapid disappearance of symptoms after glucose infusion
  • Tachycardia, palpitations, excessive sweating
  • Non-specific symptoms
Gastrinoma (Zollinger- Ellison syndrome) – is a disease characterized by hypersecretion of gastrin leading to multiple, recurrent peptic ulcers, most commonly located postbulbar, in the duodenum, but can also be located in the pancreas, with a greater potential for malignancy. As symptoms it is manifested by:
  • Diarrhoea and stools (steatosis due to decreased ability of the pancreas to secrete fat-digesting enzymes, so more fat ends up in the stool undigested, with stools having a shiny, pungent-smelling, floating appearance)
Glucagonomist – is a rare, active neuroendocrine tumour that can be found in the pancreas and secretes a hormone, glucagon, which causes blood glucose levels to rise. As symptoms it is manifested by:
  • Presence of rash/migratory necrotizing irritation and presence of diabetes mellitus
  • Glucose intolerance
  • Hyperglycaemia
  • Diaree
  • Feeling thirsty and excessive urination (polyuria)
  • Increased appetite
  • Stomatitis
  • Night-time urination (nocturia)
  • Weight loss
  • Depression
  • Deep vein thrombosis

Establishing the diagnosis

INSULINOM
– Laboratory tests – elevated insulin, elevated C-peptide, proinsulin (>22 pmol), absence of plasma or urinary sulfonylurea

GASTRINOM
– Laboratory tests – quantification of unprovoked basal and maximal gastric acid secretion, acid secretion provocation tests, serum calcium, gastrinemia assay

GLUCAGONOM
– Laboratory tests – elevated blood glucose values, blood glucagon assay (>1000pg/mL), elevated chromogranin values

For all types of benign tumours:

– Imaging tests – abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method involving visualization of intra-abdominal organs, with the possibility of visualizing a tumor formation in the pancreas, but rarely diagnostic

– Computed Tomography (CT) – makes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region the contrast substance is used; of choice; visualizes the tumor formation, provides details about the location, dimensions, relationships with surrounding anatomical structures

– Nuclear magnetic resonance (NMR) – an imaging method that uses a magnetic field and radiofrequency pulses to visualize the image of various organs and tissues of the human body; contrast material may also be used for better visualization; alternative to CT

– Endoscopic ultrasound – method combining ultrasound and endoscopy, useful when the topographic diagnosis is not resolved by the above examinations

– Somatostatin receptor scintigraphy (for diagnosis of gastrinoma)

Treatment


Insulinom
 – surgical treatment – involves resection of the tumour formation (enucleation or pancreatic resection depending on the relationship to the main pancreatic duct), either by laparoscopic or surgical approach
  • In the case of malignant tumours the treatment is similar to that of pancreatic cancer (see below)
  • In the case of glucagonoma, in addition to surgical treatment which is rarely curative, supplementation with amino acids and fatty acids, somatostatin analogues, is indicated.

Pancreatic cancer

Pancreatic cancer is cancer that develops in the pancreas, an organ located behind the stomach in the back of the abdominal cavity. It contains glands that create pancreatic juices (exocrine glands), hormones and insulin (endocrine glands). Cancer can affect both endocrine and exocrine glands in the pancreas. The most common pancreatic cancer is pancreatic adenocarcinoma, a cancer that develops in the exocrine pancreas.

There are several factors that increase a person’s risk of developing pancreatic cancer, such as:

  • Genetic mutations/abnormal changes in the AND of pancreatic cells
  • Family history of pancreatic cancer
  • Family history of genetic syndromes that may increase the risk of cancer: BRCA2 gene mutations, Lych syndrome, etc.
  • Pancreatitis – involves chronic inflammation in the pancreas
  • Diabetes mellitus
  • Smoking and alcohol consumption
  • Obesity
  • Diet: diet based on high salt intake, canned, smoked foods

Signs and symptoms

Pancreatic cancer can give you the following symptoms and signs:

  • Pain in the upper abdomen that radiates to the back – especially in cancers located in the body and tail of the pancreas
  • Lack of appetite
  • Feeling bloated
  • Weight loss without apparent cause
  • Newly diagnosed diabetes
  • Yellowing of the skin and whites of the eyes (sclerosing jaundice) – in cancers located in the head of the pancreas
  • Itchy skin (generalized itching)
  • Light-coloured chairs, white (watercolour)
  • Diaree
  • Stools that are lumpy (steatosis) – due to the decreased ability of the pancreas to secrete fat-digesting enzymes, so more fat ends up in the stool undigested, the stools have a shiny, pungent-smelling, floating appearance

Establishing the diagnosis

If you have the above symptoms, you will need to undergo the following tests and procedures to determine the diagnosis of pancreatic cancer:


–
Laboratory analysis
 – transaminases, bilirubin, alkaline phosphatase, gammaglutamyltransferase – GGT
– CA19-9 tumor marker assay

–
Imaging tests
– Abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method involving visualization of intra-abdominal organs, with the possibility of visualization of a tumor formation in the pancreas

–
Computed tomography (CT)
– takes a series of detailed images of certain regions of the body, these images are taken from different planes; for better highlighting of the region being explored, contrast material is used

–
Nuclear magnetic resonance (NMR) – an imaging method that uses a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; contrast material may also be used for better visualisation
– Positron Emission Tomography (PET) – makes an image that can help find out the extent of cancer cells throughout the body. In this examination, a radionuclide (glucose) is injected intravenously and an image is obtained that highlights glucose-using structures; neoplastic cells are more metabolically active and use glucose more intensively than normal cells.

–
Endoscopic ultrasound
 – a method that combines ultrasound with endoscopy, the method allows visualization of the tumor formation and its relationship with surrounding anatomical structures

–
Endoscopic retrograde cholangiography (ERCP)
– the procedure is performed through an endoscope, with the introduction of a radio-opaque substance into the bile duct and a concomitant radioscopy

–
Biopsy
 – manoeuvre that can be performed during echoendoscopy or ERCP, in which the doctor takes a fragment of tissue from a suspicious-looking area of the pancreas, which is then analysed under a microscope.

Treatment

Depending on the stage of your cancer and the clinical condition you have, there are several treatment options, such as surgical and/or oncological treatment.

  • Surgical treatment

If the tumour is located in the pancreatic head, a cephalic duodenopancreatectomy is performed, which involves the removal of the duodenum, the first part of the jejunum, the pancreatic head, the last part of the stomach, the cholecyst, the last part of the main bile duct leading from the liver to the duodenum and the neighbouring lymph nodes (lymphadenectomy), followed by subsequent restoration of the digestive continuity. For tumour formations located in the body and tail of the pancreas, distal pancreatectomy is performed, sometimes together with the spleen (splenopancreatectomy) or central pancreatectomy. In the case of disseminated (scattered) lesions throughout the pancreas, total pancreatectomy is performed.

  • Chemotherapy

Anti-tumour treatment, which uses certain drugs to destroy cancer cells; it can be administered before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be surgically removed, or it can be administered after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may have already spread in the body; chemotherapy can also be used as the only treatment for pancreatic cancer in advanced stages to relieve symptoms.

  • Radiotherapy

Anti-tumour treatment, which uses high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be, as with chemotherapy, of two types: neoadjuvant or adjuvant.

  • Radiochemotherapy

It involves combining chemotherapy with radiotherapy to increase their effectiveness.