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Dr Piyush Ranjan

Diabetes, jaundice can be harbinger of pancreatic cancer

The cases of pancreatic cancer, the seventh leading cause of all cancer deaths worldwide, is rising, available data suggest. According to an estimate by the Bengaluru-based National Cancer Registry Programme, about 15,000 new cases of pancreatic cancer were diagnosed in India in 2020. The current rate in India varies from 0.5 to 2.4per 100,000 persons per year among women to 0.2 to 1.8 per 100,000 persons per year among men.

It is often detected or diagnosed at a very late stage when the chance of recovery becomes grim. Drug Today Medical Times’ Rohit Shishodia spoke to Dr Piyush Ranjan, Vice Chairman of the Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, regarding the prevalence, prevention, symptoms and diagnosis of pancreatic cancer.

Here are the excerpts...
DTMT: Can you please tell our readers how pancreatic cancer spreads so fast and fails to get detected earlier?
Dr Piyush Ranjan: Pancreatic cancer is a relatively common cancer. It can be of different types, of which, adenocarcinoma is the most common type of pancreatic cancer, followed by neuroendocrine tumours.
The pancreas resides in the abdominal cavity behind the stomach. It is known as a retroperitoneal organ. The lower end of the bile duct passes through the pancreas, and structurally pancreas is divided into three parts, the head, body and tail.
The pancreas produces large amounts of secretions, which are known as pancreatic juice, and helps in the digestion of protein and fat. It also produces insulin, present in the tail of the pancreas.
The symptoms of tumours of the pancreas are distinct, depending on their location in the pancreas, and thus the tumours occurring in the head of the pancreas will have different symptoms than those occurring in the body or tail.
Pain is a common feature of all types of pancreatic tumours because the pancreas is a retroperitoneal organ, meaning it is located behind the peritoneal wall of the abdomen so, whenever a tumour grows, it infiltrates nearby nerves and causes pain.

DTMT: What are its symptoms?
Dr Ranjan: Nearly 70 to 80% of patients with pancreatic tumours experience pains that are vague and dull in nature and may last for days and months together. Often it gets dismissed as a simple acid or gastric problem.
As I told you earlier, since the pancreas is a retroperitoneal organ, it is not very well seen during routine imaging tests like ultrasound. Even if we get an ultrasound, we might miss small early tumours. So tumours which are located in the head of the pancreas usually produce early symptoms of jaundice, as liver functions tend to get derailed because the bile duct passes through it and if the tumour grows and starts compressing the head of the pancreas; it may cause jaundice or derangement in the bile duct. It may start with itching all over the body because of the hold-up of bile. So pain, jaundice, weight loss and deranged liver functions are some of the symptoms of adenocarcinoma in the head of the pancreas.
New onset of diabetes less than six to twelve months and associated with symptoms like weight loss and pain in the upper and middle abdomen, radiating  typically, the pain radiates to the back. So if a person is experiencing such combined signs and symptoms, there is a high probability of pancreatic cancer.
Neuroendocrine tumours of the pancreas will have different kinds of symptoms. If they are small, they might cause pancreatitis, and if they are hormone-producing tumours like insulinoma, they may cause repeated falls in blood sugar levels.
Moreover, there are relatively uncommon neuroendocrine tumours known as gastrinoma, that may result in the patient suffering from recurrent diarrhoea.

DTMT: Are these tumours related to pancreatitis?
Dr Ranjan: Chronic pancreatitis is a disease in which the pancreas is damaged due to many other reasons. The most common is alcohol abuse. Any person who has chronic pancreatitis has the highest chances of developing pancreatic cancer.
Other risk factors for developing ductal adenocarcinoma are smoking and obesity.
Hereditary pancreatitis is another risk factor for developing pancreatic cancers. Hereditary pancreatitis is a condition which occurs due to a specific gene known as the PRSS gene. If the father has this gene, then there is an 80% chance that children may too develop pancreatitis.
DTMT: How does it diagnose?
Dr Ranjan: The simplest way of diagnosing pancreatic tumour is by performing an ultrasound scan. Whenever we diagnose pancreatic cancer, we need to see whether it is worth operating. For that, a good CT scan is required.
 A good CT scan means a good triphasic CT scan, which is known as a pancreatic protocol CT scan because there are a lot of blood vessels, so one needs to see whether the blood vessels are involved or not.
Hence, a CT scan is a must. Sometimes MRCP (MRI) may also be required, and then a biopsy from these pancreatic lesions is done to confirm if the tumour is malignant. Endoscopic ultrasound is the easiest way of collecting samples for fine needle aspiration cytology (FNAC) biopsy from these lesions.

DTMT: How many cases do you see in your department?
Dr Ranjan: We see eight to ten cases of pancreatic cancer every month in our department. The problem is that these cases are detected in the late stage, especially the tumours of the tail of the pancreas because they are missed.

DTMT: Why are these tumours detected in the late stage?
Dr Ranjan: As the pancreas is a retroperitoneal organ, ultrasound may not be able to detect the tumour. Tumour shows symptoms only when it spreads outside the confines of the pancreas or only when the pain starts, till then, no visible signs may occur.
When the head of the pancreas is involved, one may suspect tumours early if there is jaundice. Problem is that good quality ultrasound is lacking in general and the location of the pancreas is such that it is not easy to pick it up.
The delay in diagnosis is that people ignore their symptoms, and the nature of the symptoms is such that it has a chance of being missed.

DTMT: What should be preventions?
The patients in the high-risk group, like those suffering from chronic pancreatitis and hereditary pancreatitis, should be screened regularly.
In general, avoiding alcohol, quitting smoking, maintaining ideal body weight, and avoiding food, which promotes obesity, can prevent the onset of pancreatic cancer. They are not directly related but add up to the risk of developing cancers in the pancreas.

DTMT: What is the age group of pancreatic cancer?
Dr Ranjan: It usually occurs in patients who are more than fifty to sixty years of age and is less common in younger people.

DTMT: Why does pancreatic cancer spread so fast?
Dr Ranjan: Problem is that there are many blood vessels and nerves around the pancreas. It is a small organ, and when it grows outside the confines of the pancreas, then it creates problems, and by the time it is detected, in many cases, it becomes inoperable.
Even though it seems operable, the small tumour metastasis is already there in the blood vessels. Therefore, the results of operations are unpredictable, even when performed at an early stage, and tumours may recur later.
Nowadays, good chemotherapy and radiotherapy can help in prolonging survival.

DTMT: What are the treatment options?
Dr Ranjan: The first thing one needs to assess if surgery is feasible. If a tumour is operable, that is resectable, then resection is a curative treatment.
Even after resection, one might have to undergo chemotherapy in most cases.
Many people, who are borderline resectable, might undergo preoperative chemotherapy, known as neoadjuvant chemotherapy, and after that, they are operated upon.
For patients where operation is not feasible, one has the option of palliation.
It can be in the form of pain relief and reduction of jaundice, and there are times when chemotherapy is not feasible, so we do endoscopic procedures like ERCP and stenting to bring jaundice down and then start chemotherapy later.
The other palliative procedure available for pain relief is celiac plexus neurolysis, but the average survival of these patients is very low.



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