Cancer of the pancreas

The cancer of the Pancreas , or pancreatic Adénocarcinome is a rare Cancer digestive whose forecast is dark. The neuro-endocrine tumors of the pancreas are another type of cancer, from which the presentation and the forecast are radically different. They are presented in the neuro-endocrine article Tumeur.

Epidemiology

Mortality

Annual mortality for 100 000 people is of:

Man

12,8 in Finland (country of the EU where the rate is highest)
11,8 in Suisse
10,7 in the European Union
8,3 with the Luxembourg (country of the EU where the rate is lowest)

Woman

9,8 in Sweden (country of the EU where the rate is highest)
7,8 in Suisse
7,3 in the European Union
4,9 with the Portugal (country of the EU where the rate is lowest)

Incidence

The annual indicence for 100000 people is of:

Man

13 in Finland (country of the EU where the rate is highest)
11,3 in Suisse
9,7 in the European Union
8 in France (country of the EU where the rate is lowest)

Woman

9,9 in Finland (country of the EU where the rate is highest)
7,6 in Suisse
6,5 in the European Union
4,2 in France (country of the EU where the rate is lowest)

He more often touches the man than the woman with an incidence which increases with the age (peak of frequency at 75 years for the man, 80 years for the woman). For the 65 years and more, the cancer of the pancreas concerns with Geneva approximately 5% and 6,5% of the male patients, respectively female reached cancer (at the head, for the men the Lung cancer with 22,4% and for the women the Breast cancer with 19,8%).

Risk factors

The supporting factors known are a chronic (post-alcoholic, tropical Pancréatite, or within the framework of a Mucoviscidose) or a Tabagisme.

Symptoms

The dorsal Pain, the Amaigrissement are symptoms generally found in the cancer of the pancreas, but according to the localization of the tumor in the body, the symptoms change. The pure Ictère (by biliary retention) and the Prurit (itching) caused by the ictère as well as a gross Gall bladder (and some time a Hepatomegaly) are found in the event of attack of the head of the pancreas. The cancer of the body of the pancreas more frequently involves a compression of the Estomac and a Dyspepsie. The tumor of the tail of the pancreas is often highlighted in front of the appearance of a Masse. The recent appearance of a Diabetes sweetened, recent lumbar pains with depression, can be Prodrome S of the cancer of the pancreas.

Diagnosis

The Diagnostic rests on the Biopsie pancreatic or hepatic in the event of metastases. This biopsy can be realized by trans-cutaneous way, during a Fibroscopie gastro-duodénale, or during the surgery. The abdominal scanner, IRM, and the echoendoscopy are dominating to find a pancreatic tumor. A proportioning of the ACE and Ca 19-9 can direct towards a adenocarcinomist, hormonal proportionings can characterize an endocrine tumor. The goal is to visualize the pancreatic tumor, and to seek metastases ganglionic, hepatic, or péritonéales. One also studies the relationship with the Portal vein.

The cancer of the pancreas can be presented in various forms: - in 90% of the cases, attack of the head of the pancreas - 10% of the cases correspond to a cancer of the body or tail of the pancreas

Anatomopathology

The pancreatic adenocarcinomist can present several histological forms:

the adenocarcinomist ductulaire who account for 90% of the whole of the cases and 70% of cancers of the head of the pancreas;
the mucineux cystadenocarcinomist of better forecast;
carcinome mucineux intra-ductulaire, also of better forecast;
the adenocarcinomist acinaire.

There exist cystic tumors of the pancreas which can degenerate (cystadenocarcinomist) or of the tumors of the channels excréteurs of pancreas (TIPMP).

Differential diagnosis

There exist cancers of the endocrine pancreas (very rare), revealed by their hormonal secretion, giving then: a insulinomist, glucanomist, VIPome… The tumors, often very small, are then difficult to locate and with réséquer. A ampullome (tumor of the bulb of Vater) can give a symptomatology identical to the adenocarcinomist of the head, but it is about a tumor of the bile ducts, of much better forecast. In the same way a cholangiocarcinomist of cholédoque bottom can be confused with a cancer of the pancreas. The forecast is very dark.

Classifications

classification TNM (UICC 2002)

T (Tumor)

Tx insufficient Information to classify the primitive tumor
T0 No sign of primitive tumor
Tis in situ Carcinome
T1 Tumor limited to the pancreas, <2 cm in its largeer diameter
T2 Tumor limited to the pancreas, > 2 cm in its largeer diameter
T3 Tumor extended directly to any of the following bodies: Duodenum, bile duct, fabric peripancreatic.
T4 Tumor extended directly to any of the following bodies: Stomach, Spleen, Colon, large adjacent vessels

NR (regional Adenopathies)

Nx insufficient Information to classify the regional adenopathies
N0 No regional ganglionic metastasis
N1 Invasion of the regional lymphatic ganglia

N1a Invasion of only one ganglion
N1b Invasion of several ganglia

M (remote Metastases)

MX insufficient Information to classify remote metastases remotely
M0 No remote metastasis
M1 Presence of metastasis (S)

Factors forecast

The cancer of the pancreas is a tumor of very bad forecast.

When the diagnosis of cancer of pancreas is carried, the chance of survival at 5 years is from 1 to 4%. Twenty percent of the operated patients in a complete way are alive at 5 years. On the other hand for the nonoperable and metastatic patients median survival is 6 months and survival at 5 years is null.

Treatment

Taking into account the gravity of the forecast, it is legitimate to consider an aggressive treatment among patients in general good state for which an optimal surgical treatment is possible. When the patient is not operable (bad general state, nonoperable lesion, metastases) quality of life must be preserved more the possible for a long time. The care of support has a dominating place then.

Therapeutic methods

Surgery

The Chirurgie was the treatment of first intention for a tumor not exceeding a certain volume and not presenting metastasis or of too intimate contact with the portal vein. But the localization of this tumor makes that it is not easy access (many veins are behind). In addition, of the recent protocols show an advantage to practice a radio-chemotherapy pre and post operational in selected cases. The Exérèse is not possible that in 20% of the cases. The loco-regional relapse occurs however in 70 to 80% of the cases. The surgery of exérèse of the head of the pancreas ( cephalic duodeno-pancreatectomy ) is heavy, because of the venous reports/ratios, digestive, and biliary. It can be proposed only with one patient in general good state, in the absence of respiratory or cardiac tare. For the tumors of the tail of the pancreas, the surgery of reference is the caudal spleno-pancreatectomy.

In the case or any curative surgery is not possible, one will prefer, if need be, a palliative surgery aiming at treating the symptoms, by allowing the flow of the bile and the bolus: double bilio-digestive derivation . These derivations are more and more often carried out by endoscopic way, with installation of endoprothèses biliary and duodénales.

The radiotherapy or radio-chemotherapy

In the event of evolved/moved tumor, the radio-chemotherapy is used either after the surgery or in the place of this one. The radiotherapy delivers 45 to 50 Gy into 5 to 6 weeks and is associated with the continuous 5-FU with low dose. Used following the surgery, in situation " adjuvante" , the radiochimiothérapie allows a reduction in the local relapses but the profit in survival remains weak.

Chemotherapy

The Chimiothérapie is used mainly in metastatic situation, in complement of the symptomatic treatments (surgery of derivation, nutrition, treatments antalgic, psychological support). The products used are the 5-FU, the Cisplatine, the Gemcitabine and the Oxaliplatine. In the metastatic diseases, the palliative effect is shown for the gemcitabine and the combination 5-FU and cisplatine. In auxiliary situation, i.e. after a surgery with curative aiming, chemotherapy makes it possible to deduce the risk from repetition or to delay this one.

The protocols of chemotherapy validated in the cancer of the pancreas are:

Gemcitabine

Gemcitabine 100 mg/m ² every week 7 weeks over 8 then 3 weeks out of 4

Cisplatine - LV5FU2 simplified

Cisplatine 50 mg/m ²
Acid Folinique 400 mg/m ²
5FU 400 mg/m ² in J1
5FU 2400 mg/m ² during 44 hours

GEMCIS

Gemcitabine 1000 mg/m ²
Cisplatine 25 mg/m ²
J1, J8, J15 taken again in J28

GEMOX

Gemcitabine 1000 Mg m ² in J1
Oxaliplatine 100 Mg m ² in J2
J1 = J14

Therapeutic strategies

The therapeutic strategies presented here are inspired by the reference frame of the French federation of Digestive Cancerology of 2005. The modes of treatment can vary from one country to another and area to another.

Tumor réséquable

For tumors of small size, at patients able to support a surgery of éxérèse with curative aiming. the treatment of reference is a surgery with curative aiming of cephalic duodeno-pancreatectomy type for the tumors of the head of the pancreas and a caudal spleno-pancreatectomy for the lesions of the tail of the pancreas. The auxiliary treatment will depend on the quality of the résection.

in the event of complete résection with sufficient margins (résection R0), the auxiliary treatment will include/understand a chemotherapy LV5FU2 for 6 months.
in the event of microscopic incomplete résection (R1) or macroscopic (R2) the auxiliary treatment will include/understand either a chemotherapy of the 5FU-cisplatine type or gemcitabine for six months or a radio-chemotherapy.

Nonoperable tumor

If the tumor is not réséquable from the start but which it is probable that a treatment by radiotherapy or chemotherapy will make it possible sufficiently to reduce the tumor to make it operable, it is possible to begin the treatment by an association radio-chemotherapy (with 5FU-cisplatine) and to revalue the operability of the lesion thereafter. If the lesion is definitively not operable, the choice possible between a chemotherapy only an association of radio-chemotherapy or a chemotherapy is followed of an association of radio-chemotherapy for the patients whose tumor decreased under chemotherapy.

Metastatic tumor

1st line: gencitabine or 5FU-cisplatine 2nd line: gencitabine, GEMOX or 5FU-cisplatine according to the first line.

Therapeutic tests

For the operated patients in a satisfactory way, the current tests study the interest of an auxiliary treatment including/understanding a chemotherapy containing Gemcitabine, followed by an association radiochimiothérapie, also with gemcitabine. For the patients whose tumor is not operable, one evaluates an association radio-chemotherapy with a protocol of chemotherapy of the type GEMOX (GERCOR DO3-1). For the patients in metastatic phase, targeted therapies are introduced. Most promising to date are the Erlotinib and the Bévacuzimab. The erlotinib is a tyrosin kinase inhibiter which showed a certain interest in metastatic lung cancer. The bévacuzimab is an antibody anti VEGF, used systematically in the cancer of the colonist and whose interest is specified in breast cancer and of the lung.

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