Pancreas

These secondary signs include: [2,3] || Exocrine cell (ductal glands) Endocrine cells (hormonal gland)
 * **Epidemiolgy:** || The overall incidence of pancreatic cancer has been relatively stable for decades. The male rate has been stable since 1993, and the incidence in women has been increasing by 0.6% per year since 1994 (They think this has to do with the changing smoking rates for men and women). Pancreatic cancer is 13th in incidence worldwide, but 8th as the cause of cancer death.[1] ||
 * **Etiology:** || Pancreatic cancer can come from the exocrine and endocrine portions of the pancreas. The exocrine portion accounts for 95% of pancreatic cancer. This includes the ductal epithelium, acinar cells, connective tissue, and lymphatic tissue. About 75% of pancreatic carcinomas are in the head/neck area of the pancreas, 15-20% in the body, and 5-10% in the tail. Some of the risk factors for pancreatic cancer are: [1]
 * Smoking (accounts for up to 30% of cases)
 * Obesity and dietary factors
 * Diabetes mellitus
 * Chronic pancreatitis
 * Genetic factors (mutations of the PRSS1, APC, MSH2, MLH1, and CDKN2A genes)
 * Race factors (black males have the highest rate of pancreatic cancer) ||
 * **Signs & Symptoms:** || Jaudice, which may be present in up to 50% of patients affected by this disease, is one of the most common signs. In addition, weight loss and abdominal pain are common signs. Other signs and symptoms of pancreatic cancer are non-specific and require close attention by physicians to ensure that appropriate diagnostic tests are done.
 * Anorexia
 * Pruritis
 * Alterations in bowel habits
 * Thrombophlebitis
 * Depression
 * Glucose intolerance [2] ||
 * **Diagnostic Procedures:** || * Computed tomography (CT) is the initial test done for evaluation of symptoms suggestive of pancreatic cancer.
 * T1- and T2- weighted magnetic resonance imaging (MRI) may be useful.
 * Endoscopy, or endoscopic retrograde cholangiopancreatography (ERCP) is used for visualizing the common and pancreatic ducts in order obtain tissue biopsy or cytologic samples. In addition, the test may indicate obstruction of the common bile duct, as well as a stricture in the pancreatic duct.
 * Endoscopic ultrasonography (EUS) can guide the use of fine-needle biopsy. It has an accuracy of 75-92% in identifying pancreatic neoplasms.
 * Percutaneous needle biopsy, using either CT or ultrasonographic guidance demonstrates high sensitivity and specificity in the diagnosis.
 * Liver function tests have the ability to possibly identify an obstructive component.
 * Tumor marker CA-19-9
 * Laparoscopy to identify peritoneal implants or metastases on the liver surface.
 * **Histology:** || Pancreatic cancers are mainly adenocarcinomas which are cancer of the epithelium in glandular tissue and make up 80% of all histology’s that are diagnosed.[2] Some other histological types may include islet cell tumors, acinar cell carcinomas and cystadenocarcionmas.[3] there are two different subcatigores to pancreatic cancers as far a cell types and those are endocrine and exocrine cells.
 * Acinar cell carcinoma,(most common, arising in ducts of the pancreas)
 * Adenosquamous carcinoma
 * Squamous cell carcinoma
 * Giant cell carcinoma
 * Pancreatic neuroendocrine tumors (NET)
 * Inslet tumors ||
 * **Lymph node drainage:** || Lymph nodes drainage associated with pancreatic cancer are.
 * Superior pancreaticoduodenal
 * Inferior pancreaticoduodenal
 * Porta hepatitis
 * Celiac nodes
 * Mesenteric node
 * Suprapancreatic nodes
 * Paraaortic nodes
 * Splenic hilar nodes (for tumors in tail of pancreas) ||
 * **Metastatic spread:** || In general cancers of the pancreas are locally invasive. [3] Direct involvement into the duodenum, stomach and colon are common sites due to the proximity of organs. Once the tumor has moved into the lymph systems the metastasis sites can include the liver, lungs and peritoneum. Lesions in the tail and body have a 75% chance of metastases to the liver and peritoneal cavity verse 33% of lesions that began in the head. [2] ||
 * **Grading:** || Histologic tumor grade (sometimes called the Bloom-Richardson grade, Scarff-Bloom-Richardson grade, or Elston-Ellis grade) is based on the arrangement of the cells in relation to each other: whether they from tubules; how closely they resemble normal breast cells (nuclear grade); and how many of the cancer cells are in the process of dividing (mitotic count)[4]. This system of grading is used for invasive cancers but not for in situ cancers[4].

-Grade 1 (well differentiated) cancers have relatively normal-looking cells that do not appear to be growing rapidly and are arranged in small tubules.

-Grade 2 (moderately differentiated) cancers have features between grades 1 and 3.

-Grade 3 (poorly differentiated) cancers, the highest grade, lack normal features and tend to grow and spread more aggressively." ||
 * **Staging:** || ====== A staging system is a standardized way in which the cancer care team describes the extent that a cancer has spread[5]. The main system used to describe the stages of cancers of the pancreas is the American Joint Committee on Cancer (AJCC) TNM system. The TNM system for staging contains 3 key pieces of information[5]: ======
 * ====== T describes the size of the primary tumor(s), measured in centimeters (cm), and whether the cancer has spread within the pancreas or to nearby organs. ======
 * ====== N describes the spread to nearby (regional) lymph nodes. ======
 * ====== M indicates whether the cancer has metastasized (spread) to other organs of the body. (The most common sites of pancreatic cancer spread are the liver, lungs, and the peritoneum - the space around the digestive organs.) ======

Numbers or letters appear after T, N, and M to provide more details about each of these factors[5]:

 * ====== The numbers 0 through 4 indicate increasing severity. ======
 * ====== The letter X means "cannot be assessed" because the information is not available. ======
 * ====== The letters "is" mean "carcinoma in situ," which means the tumor is contained within the top layers of pancreatic duct cells and has not yet invaded deeper layers of tissue[5]. ======

=
Stage 0 (Tis, N0, M0): The tumor is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside of the pancreas. These tumors are sometimes referred to as pancreatic carcinoma in situ or pancreatic intraepithelial neoplasia III (PanIn III). ======

=
Stage IIB (T1-3, N1, M0): The tumor is either confined to the pancreas or growing outside the pancreas but not into nearby large blood vessels or major nerves. It has spread to nearby lymph nodes but not distant sites. ======

=
Stage III (T4, Any N, M0): The tumor is growing outside the pancreas into nearby large blood vessels or major nerves. It may or may not have spread to nearby lymph nodes. It has not spread to distant sites. ======

|| || 2. Chao KS, Perez CA, Brady LW. //Radiation Oncology: Management Decisions//. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 3. Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. St. Louis, MO: Mosby; 2010. 4. Pancreatic Cancer. //Cancer Compass//. Available at: []. Accessed on: June 6, 2012. 5. Pancreatic Cancer. American Cancer Society. 2012.Available at: []. Accessed on: June 6, 2012.
 * **Radiation side effects:** || ====== With pancreatic cancer radiation therapy, the side effects depend on the treatment dose and the part of the body that is treated[5]. During radiation therapy people are likely to become very tired, especially in the later weeks of treatment. Getting plenty of rest is important[5]. It is common to lose hair in the treated area and for the skin to become red, tender, and itchy[5]. There may be permanent darkening or "bronzing" of the skin in the treated areas. This area should be exposed to the air as much as possible but protected from the sun, and it is important to avoid wearing clothes that rub. Patients will be shown how to take care of the treated area. Lotion or cream should not be used on the treated skin without the doctor's advice[5]. Radiation therapy to the pancreas and nearby tissues and organs may cause nausea, vomiting, diarrhea, or problems with digestion[5]. Usually, the doctor can suggest certain diet changes or medicine to treat or control these problems. In most cases, side effects go away when pancreatic cancer treatment is over[5]. ====== ||
 * **Prognosis:** || The expected survival is 11 to 14 months. Following difficult surgery then chemotherapy and radiation, the survival rate of pancreatic cancer can be 18 to 29 months. [3] ||
 * **Treatments:** || Depending on the stage of the disease, a few different surgical procedures are available for resection of the disease. After surgery radiation is used concominantly and sometimes after chemo to treat any disease left behind from surgery. When planning radiation treatments, some dose limiting structures are the small intestine, stomach, liver, kidneys, and spinal cord (TD 5/5’s listed below). Doses range from 45 to 50 Gy in 180cGy fractions. The kidneys are the most limiting structure because they are close and most certainly in the treatment area and they have a low tolerance to radiation.[2] ||
 * **TD 5/5:** || TD 5/5 is a statistical guideline to consider which states that there has been a five percent probability of complication in five years. These values are based on a 200cGy 5 fraction a week treatment schedule.[6] The table includes the five most commonly evaluated structures for irradiation
 * **References:** || 1. Dragovich T, Harris JE, Erickson RA, et al. Pancreatic cancer. //Medscape.// Sept. 13, 20122. Available at: [|http://emedicine.medscape.com/article/280605-overview#showall]. Accessed June 4, 2012.

6. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys. 1991 ||

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