Latest therapies for pancreatic tumors
Every day, around 1,200 people worldwide receive a pancreatic cancer diagnosis. In 2018, there were nearly 450,000 pancreatic tumors among the 18 million global cancer cases. The pancreas is one of the body’s most essential glands. It plays two vital roles: secreting insulin to regulate blood sugar and releasing enzymes for digestion. Unfortunately, no screening tests currently exist to detect pancreatic cancer early. Risk factors include smoking, obesity, chronic pancreatitis, and genetic predisposition.
Pancreatic cancer gained public attention when celebrities like Luciano Pavarotti and Patrick Swayze were diagnosed. Despite its severity, there is now some hope. Surgical advancements can now save lives and extend life expectancy for previously deemed untreatable patients. These are often cases of borderline resectable or locally advanced pancreatic cancer. One of the leading experts in this field is Prof. Dr. Güralp Ceyhan. He heads the Hepato-Pancreatico-Biliary unit at Acıbadem Maslak and Altunizade Hospital.
Modern therapy protocols include neoadjuvant chemotherapy to shrink tumors and slow their growth. This advanced treatment is also available at Acıbadem Maslak and Altunizade hospitals. It allows surgeons to operate on patients who were once considered untreatable. Here’s a brief overview of pancreatic cancer and available treatment options.
The Most Common Pancreatic Tumors
What are the most frequent pancreatic tumors you encounter in your practice?
Prof. Dr. Güralp Ceyhan: The most common and concerning pancreatic tumor is pancreatic cancer, often diagnosed as pancreatic ductal adenocarcinoma. We also see more cystic pancreatic tumors, such as intraductal papillary mucinous neoplasms (IPMN), thanks to advanced imaging techniques. Twenty years ago, these tumors were hard to detect, but now we can diagnose them more easily. This is why the number of cases has increased significantly. Treating these tumors remains challenging.
There are two main types of IPMN tumors: those affecting the main pancreatic duct and those impacting the side branches. Tumors in the main duct have a higher cancer risk. Therefore, they require a similar treatment to pancreatic cancer, including oncological resection. Side-branch IPMN tumors are less aggressive, and their malignant potential is uncertain. There is ongoing debate about whether to monitor or surgically remove these tumors.
Another type of pancreatic tumor is neuroendocrine tumors, which can be either hormone-active or non-active. Most pancreatic neuroendocrine tumors are non-active.
Is There a Link Between Diabetes and Pancreatic Disorders?
Prof. Dr. Güralp Ceyhan: There is a neuroendocrine hormone-active pancreatic tumor called insulinoma, which causes excess insulin production. However, sudden diabetes can sometimes indicate pancreatic cancer. Sudden diabetic symptoms in a person with normal blood sugar level can also be a sign of pancreatic cancer. Removing the malignant tumor often resolves the diabetes. So, sudden-onset diabetes should not be ignored as it could be a symptom of pancreatic cancer.
Symptoms of Pancreatic Cancer
What symptoms of pancreatic tumors should prompt patients to see a doctor?
Prof. Dr. Güralp Ceyhan: Consider this scenario: a patient plays golf on Sunday and wakes up with yellowish skin on Monday. This jaundice leads to a pancreatic cancer diagnosis with liver metastases. This leaves the patient with a life expectancy of up to one year. This happens in over 50% of cases, where patients remain asymptomatic until the advanced stages. The remaining patients might develop early jaundice, experience pain, lose appetite, lose weight, or suffer from unexplained nausea and bloating. If pain is the first symptom, the prognosis is often poor. Unfortunately, there is no specific symptom directly linked to pancreatic cancer.
How would you describe the pain?
Prof. Dr. Güralp Ceyhan: The pain is intense and radiates to the back. It is common in chronic pancreatitis but can also occur in pancreatic cancer cases.
Advances in Diagnosing Pancreatic Tumors
What are the advances in early diagnosis of pancreatic tumors?
Prof. Dr. Güralp Ceyhan: I want to highlight a few points about cystic tumors. Early detection of pancreatic cancer is almost impossible, unlike colon cancer, which can be found early through colonoscopy. Pancreatic cancer is often discovered by accident during routine check-ups. A doctor might see something unusual on ultrasound and confirm it with a CT scan.
Gastroscopy can examine the stomach and duodenum but not the pancreas. Routine endosonography is possible, but it is not yet recommended. This means no routine check-up can reliably detect pancreatic tumors at an early stage. Early detection, such as liver tumors, relies on a good doctor who notices something unusual during a routine ultrasound.
There are also tumor markers, like CA 19-9, which can be elevated in pancreatic cancer. However, this marker is not always present. After tumor removal, CA 19-9 levels typically decrease. Monitoring these levels can help detect recurrences. However, if CA 19-9 was not elevated before surgery, it cannot be used for follow-up. Elevated CA 19-9 can indicate other issues, such as inflammation. And yet it cannot reliably detect early-stage pancreatic cancer, unlike PSA for prostate cancer.
Performing Operations for Pancreatic Cancer
How does modern technology assist you in performing successful operations?
Prof. Dr. Güralp Ceyhan: Success in treating pancreatic cancer depends on a multidisciplinary team. This includes experienced surgeons, interventional gastroenterologists, oncologists, radiotherapists, and interventional radiologists. These experts collaborate to treat patients with chronic pancreatitis, pancreatic cancers, and advanced liver tumors. The role of minimally invasive surgery, like laparoscopic and robotic surgery, is growing in gastrointestinal oncology. Robotic surgery allows for more precise removal of lymph nodes, which can improve patient outcomes. It also helps patients recover faster with smaller scars and less pain. This combination of advanced technology and a skilled team enhances treatment success.
Modern Therapies Prolonging Life in Pancreatic Cancer
What are the latest treatment protocols for pancreatic cancer?
Prof. Dr. Güralp Ceyhan: This is an exciting time for pancreatic cancer treatment. About 20% of patients have tumors located in the pancreas without metastasis or vessel involvement. For these patients, we can perform oncological resection followed by adjuvant chemotherapy. In our recent study published in Annals of Surgery, 40% of these patients achieved a five-year survival rate with no residual tumor. This is significant, as global survival rates are often around 20%.
Around 20-25% of patients have locally advanced cancer with vessel involvement. A few years ago, we treated them with palliative care, similar to those with distant metastases. Now, with neoadjuvant chemotherapy regimes like FOLFIRINOX or Gemcitabine Abraxane, over 50% of these patients become resectable. Even if the tumor does not shrink, surgery may still be possible if the cancer cells are inactive.
Challenges in Diagnosing Neoadjuvant Therapy Success
How do you determine the effectiveness of neoadjuvant therapy?
Prof. Dr. Güralp Ceyhan: Imaging methods like CT or MRI often fail to show if neoadjuvant therapy has been effective. Tumors might appear unchanged, but they could be inactive. This can only be confirmed during surgery, where tissue samples are analyzed. Therefore, we should give these patients a chance for surgery, even if imaging suggests otherwise. Neoadjuvant therapy reduces the risk of complications, such as pancreatic fistula, by modifying the pancreatic tissue positively. This reduces the risk of death after surgery, making it safer to perform complex operations that were previously considered impossible.
Is Pancreatic Cancer Still a Deadly Diagnosis?
Can you say that pancreatic cancer is less deadly now?
Prof. Dr. Güralp Ceyhan: Pancreatic cancer remains a serious and aggressive disease. However, we now have hope for patients who were previously considered untreatable. With advancements in neoadjuvant therapies and surgical techniques, we can help more patients than ever before. It is still a challenging disease, but we are making progress in prolonging life and improving outcomes.
