Treatment
Surgery can be performed on a patient in whom the tumour has not yet spread, i.e. the tumour is less than 2 centimetres in size, has not grown into surrounding tissue and has not already spread (metastasised) to other organs. This situation exists in about 15 – 20 % of those affected. The remaining 80 % must be treated with a palliative (pain-relieving) approach.
The operation is called Whipple surgery, named after George Hoyt Whipple, who was the first surgeon to perform this operation. The Whipple operation is also called duodenopancreatectomy, which means the removal of the pancreas and duodenum. In a Whipple procedure, which takes about 6-8 hours, the surgeon removes the duodenum, pancreas head, bile duct and gall bladder, the lower part of the stomach and all lymph nodes located near the aforementioned structures.
If the tumour is located in the area of the body or the tail of the pancreas, these structures are also removed. In this situation, there may be the possibility of a stomach-preserving operation, since anatomically speaking, the tail area of the pancreas is rather more distant, so that the stomach can be left. Through the generous removal of all structures one tries to achieve a so-called R0 situation, i.e. one wants to achieve that on one side all tumor tissue is removed, as well as the surrounding tissue, in which possibly smallest micrometastases are present, is removed.
When removing the entire pancreas, care must be taken to replace all functions of the pancreas with medication. Insulin must be administered in the form of injections, as the operation has created a metabolic situation similar to diabetes. Digestive enzymes can also be administered in the form of medication.
This is very important to allow normal metabolism and digestion of the food components of carbohydrates, proteins and fats. After the operation, accompanying chemotherapy with gemcitabine or 5-FU (5- Flourouracil) can be carried out to prolong the patient’s life. The mortality rate after surgery is about 5% in larger medical centres.
The chance of survival after the operation is about 5 years in 20% of those treated. In the best case, when the tumour has not spread and is smaller than 2 cm in diameter, the patient has a 40% chance of survival after the operation after 5 years. In general, the prognosis of the tumour is very poor, the average survival time is 8-12 months. Even with the best care and sufficient follow-up, almost all patients die within the first 2 years after diagnosis.
Inoperable pancreatic cancer
If the tumour is inoperable, for example, because it has already spread, has grown into surrounding organs or other concomitant diseases lead to an unstable circulatory situation, palliative therapy may be considered. In the palliative therapy situation, the improvement of the quality of life is in the foreground. The patient should be free of complaints, the highest priority in this context is freedom from pain.
The mean survival time in palliative therapy is 6-9 months. Radiation therapy and chemotherapy can be used to support the patient. Patients with pain that is difficult to adjust can benefit from local radiation.
In this case, radiation is applied in the area where the pancreatic cancer is located. Bone metastases can also be irradiated, which usually lead to very severe pain and thus cause less severe symptoms. Other ways of reducing pain include inserting a pain catheter into the spinal cord or blocking the nerve plexus, which is responsible for transmitting information about the pain from the pancreas to the processing pain centre in the brain.
Chemotherapeutic agents can also be used. These substances are most suitable for younger patients with a good general condition who wish to be treated. Important substances are gemcitabine, 5-FU (= 5-fluorouracil) and erlotinib.
Gemcitabine has an inhibitory effect on the growth of tumour cells. Typical side effects are disturbances in the blood count, a reduction in various blood cells, and gastrointestinal complaints such as nausea, vomiting and diarrhoea. There may also be negative effects on kidney, lung and hair.
5- Fluoruracil is a chemotherapeutic agent which makes it impossible to build up the DNA in the cancer cell by incorporating the wrong building blocks and thus impeding the growth and cell proliferation of the tumor. The most common side effects are nausea, vomiting and diarrhoea. Erlotinib inhibits receptors on the tumor cell that take up information for growth.
The most common side effects of erlotinib are loss of appetite and diarrhoea, acne-like skin reactions may occur and the drug often leads to rapid fatigue. Approximately 5 %- 25 % of patients respond to radiation and/or chemotherapy. Good results have been achieved with irradiation in terms of pain relief.
With a combination of gemcitabine and 5-fluoruracil, there is only a very slight improvement in survival time and thus a low chance of survival. All in all, pancreatic cancer is a malignant disease with a very poor chance of survival, which cannot achieve the desired success with the support of various therapeutic approaches. It is not possible to prolong the patient’s life satisfactorily, nor is it possible to cure an even smaller percentage of patients.
Statistically, this means a 5-year survival rate of 1%. In patients who were initially treated with a curative approach and in patients where it was possible to remove the tumour completely, the 5 year survival rate is approximately 5%.
