Pancreatic Cancer and Treatment
Pancreatic cancer is one of the most common and difficult to treat cancer types of our time. Anadolu Health Center General Surgery Specialist Prof. Dr. Süleyman Yedibela explained the treatment methods of pancreatic cancer…
Pancreatic cancer is the fourth leading cause of all cancer deaths in both men and women. In pancreatic carcinoma, precursors with different genetic profiles can be distinguished (PanIN 1 – 3 and IPMN = intraductal papillary-mucinous neoplasia of the pancreas). Microscopic diagnosis of pancreatic cancer is made by WHO (World Health Organization) within the framework of the classification of all pancreatic tumors.
The most common type of pancreatic cancer is the type that originates from the cells of the pancreatic ducts (exocrine function of the pancreas), which enable the food we consume to be broken down into the smallest molecules and secrete pancreatic juice.
Tumors can develop in three parts of the pancreas (head, body, and tail). Approximately 60-70 percent of pancreatic carcinomas originating from all pancreatic juice-secreting cells are located in the head of the pancreas, 10-15 percent are in the body region and tail of the pancreas.
Surgical approach in pancreatic cancer
The only potential curative treatment for exocrine pancreatic cancer is surgery.
Special chemotherapy, radiochemotherapy or radiation therapy is not applied to patients with pancreatic carcinoma who are determined to have a chance for surgery. If distant metastases (organ metastases, metastases spread to the abdominal membrane, lymph node metastases considered as distant metastases) are detected, surgery for pancreatic cancer is not performed.
Surgical procedures are part of the framework that we define at Anadolu Health Center together with pancreatic oncology specialists and gastroenterology, radiation therapy and interventional radiologists at our weekly tumor board, in line with national/international guidelines and research results. We offer you the best possible treatment option based on current guidelines and your personal findings. You can also get a second opinion from us.
We attach great importance to offering you the most modern oncological surgical techniques as well as comprehensive and innovative treatment options (chemotherapy, immunotherapy, radiation).
Determining the feasibility of surgery (resectability)
Assessment of the feasibility of surgery requires computed tomography (CT), nuclear spin (MRI) and, if necessary, positron emission tomography (PET)-CT and – in case of suspicion, comprehensive and high-quality staging diagnostics (=environmental diagnostics).
Only about 15-20 percent of all patients with pancreatic cancer have a chance for surgery. Approximately 5-10 percent of all patients have a borderline chance of being operated on.
Resectability criteria in pancreatic cancer (borderline)
If the primary tumor surrounds the celiac region or the artery that feeds the entire small and large intestine (superior mesenteric artery), surgical removal of the tumor should not be performed. If the veins that carry all the blood from the small and large intestine to the liver (portal vein and/or superior mesenteric vein) or the vein that carries the blood from the spleen to the liver (splenic vein) are surrounded by the tumor, this should not be considered as a criterion for not performing the surgery.
The criteria that determine whether the surgery can be performed (resectability criteria) are (I) the veins leading to the liver (V. mesenterica superior/V. porta) being surrounded by cancer in a way that makes it impossible to repair, (II) the artery feeding the intestines (A. mesenterica superior) being surrounded by cancer. ) tumor-vessel contact with more than 180°, (III) tumor-vessel contact with the artery feeding the liver (hepatic artery) that cannot be repaired, and (IV) tumor-vessel contact with the celiac trunk more than 180° (see table above ).
Pancreatic head resection
Surgical treatment of pancreatic carcinoma should aim at complete removal of the tumor. In the case of locally limited tumors, these standard resections can be performed as partial removal of the pancreatic head = pancreaticoduodenectomy, removal of the tail of the pancreas = distal pancreatectomy, complete removal of the pancreas = total pancreatectomy, and removal of the necessary lymph nodes. In cases where the veins leading to the liver (mesenteric-portal veins) or adjacent organs are involved, a surgery that completely eliminates the disease is usually possible, with a slight increase in the patient’s complication rate, but with equivalent oncological results. This decision should be within the scope of a decision made as a result of council approval around the surgical treatment of pancreatic carcinoma, most importantly the chemotherapy (adjuvant) given after surgery. Removal of the head of the pancreas Kausch-Whipple It can be done in the classical way (including the lower third of the stomach, duodenum, bile duct, gallbladder, head of the pancreas) or as a protective method according to Traverso-Longmire (the stomach is left completely according to the classical version) (images below). ).
Reconstruction after pancreatic head resection
The upper small intestine is connected to the remaining pancreas on the left, allowing new pancreatic fluid to flow into the intestine. In addition, thanks to the connection of the main bile duct with the upper small intestine, the flow of bile into the intestine is ensured.
The last new connection is the connection of the stomach (here the classical surgery according to Kausch-Whipple) and the upper small intestine.
Left pancreatic resection
Tumors in the body and tail of the pancreas require removal of the spleen (splenectomy), and if this surgery is performed due to cancer, removal of the tail of the pancreas and the lymph nodes in this area (=distal pancreatectomy).
According to the results of many studies, laparoscopic (= minimally invasive) left pancreatic resections have shown that complete tumor removal is possible at a rate comparable to open surgeries, and the number of lymph nodes removed is also possible at similar levels. However, in most studies, it is not possible to say to what extent tumor patients benefit from laparoscopic surgery and the advantages that may come with it. The main reason for this is the strong patient selection in this group of patients and the fact that the patients are treated with open surgery method.
Removal of the entire pancreas (total duodenopancreatectomy)
In case of extensive tumor involvement or a tumor located in the center of the pancreas that cannot be resected by the above surgical methods, removal of the pancreas, duodenum, spleen and lymph nodes in this region may be required along with lymphadenectomy.
Extended pancreas surgery strategies
If a good oncological result that will cure the patient can be obtained, surgical treatment should be aimed by removing the pancreas and adjacent organs or tissues. Extended interventions include repairing the vessels with artificial vessels after removing them along with the tumor (veins or arteries surrounded by the tumor), as well as removing the neighboring organs with tumor involvement by completely clearing them of the tumor. Numerous studies conducted in recent years have shown that surgical complications do not increase in surgeries involving the removal of veins and that long-term survival is equivalent to surgeries without vein involvement, performed by surgeons with appropriate experience. In the presence of a single metastasis (e.g. in the liver) and in cases of recurrence, their surgical removal is evaluated individually and all findings are discussed in the (interdisciplinary) tumor council with the participation of doctors from different departments to achieve the best result.