The most important treatment for pancreatic cancer is surgery. The goal of surgery is to remove the tumor tissue and surrounding lymph nodes as completely as possible. This is possible only when the tumor is confined to the gland and can be removed within healthy tissue. Thus, the surgeon removes not only the tumor itself, but also the healthy tissue that extends beyond it. This is necessary so that there are no tumor cells left in the body that could develop into a new tumor.
The type and extent of the operation depend on the location of the tumor inside the gland, on the type of tumor and on the stage of the tumor process. With a tumor of the head of the pancreas, which is more common, depending on the stage and form of the disease, not only the right part of the gland affected by the tumor is removed, but also in most cases the gallbladder, the lower part of the common bile duct, the duodenum and sometimes also part stomach (so-called Whipple operation). In some cases, complete removal of the pancreas (total pancreatectomy) is necessary.
Because this operation removes the duodenum, the connection between the stomach and the small intestine is first interrupted. This also applies to the outflow to the duodenum and small intestine of bile produced in the liver. This connection must be restored in the second part of the operation (reconstruction) in order for the patient to eat again and for the flow of bile into the small intestine. This is done by connecting a loop of the small intestine to the stomach or the remainder of the stomach (gastroenterostomy), or to the common bile duct (biliodigestive anastomoses). In a Whipple operation, the duct of the remaining pancreas is either diverted into the intestine (pancreaticojejunostomy) through a loop of intestine or closed.
The Whipple operation is a large and complex intervention, however, at present in centers with relevant experience, it no longer poses a high risk in terms of complications. However, the main condition for the implementation of this operation is the good general condition of the patient and the absence of serious concomitant diseases. After surgery, you should expect a three to four week hospital stay and more than a week for the subsequent recovery period. If the tumor is actually confined to the pancreas, a cure can be achieved with surgery.
When the tumor is localized in the tail of the pancreas, as a rule, as a rule, only the part of the organ affected by the tumor (the so-called left-sided resection) and the spleen are removed. In this case, more extensive reconstructive actions are not required. In many cases, curative surgery is not possible. If the tumor is already too large to be completely removed at the time of diagnosis, one usually attempts to slow the growth of the tumor and alleviate patient complaints with chemotherapy, a combination of chemotherapy and targeted therapy with the tyrosine kinase inhibitor erlotinib, or a combination of chemotherapy and radiation therapy. Surgery may be needed to relieve symptoms associated with the tumor or to treat or prevent complications. This situation in pancreatic cancer can occur when the bile ducts, the pylorus or the duodenum are compressed due to the growth of the tumor.
Treatment after surgery
If the tumor is completely removed by surgery, then therapy is usually completed. If the tumor cannot be completely removed within healthy tissue, radiation therapy may be performed after surgery. It is often combined with chemotherapy. The purpose of this maintenance (adjuvant) therapy is to destroy the remaining tumor cells in the body. Whether postoperative as well as preoperative, radiochemotherapy or chemotherapy alone can reduce the possibility of disease recurrence is currently being investigated.
Chemotherapy aims to kill cancer cells throughout the body with drugs that inhibit cell growth (cytostatics). Cytostatics work very well on rapidly growing cells, this property is especially important in the presence of cancer cells.
Treatment of pancreatic cancer with cytostatics alone is not possible. There is evidence that in the presence of metastases in the lymph nodes, postoperative chemotherapy has a beneficial effect on the course of the disease. So she lets for a while stop tumor growth and increase duration life patients. In addition, it can relieve symptoms and pain caused by the tumor, as well as stop weight loss. In some patients, chemotherapy can even achieve a significant reduction in the tumor. In order to achieve the greatest possible effect on tumor cells and reduce the risk of side effects, a combination of different acting cytostatics can be used. In order to obtain the greatest possible effect on the tumor cells and reduce the risk of side effects, the use of a combination of different types of cytostatics can be undertaken. Treatment is carried out in several cycles over several weeks. There are long recovery phases between individual cycles. Treatment cycles are most often repeated 3 to 6 times. How many cycles need to be carried out in each case depends primarily on how the patient tolerates the treatment and how it affects the tumor.
Gemcitabine has been established as the primary therapy for more than 10 years. In combination with the cytostatic capecitabine and the growth factor receptor tyrosine kinase inhibitor erlotinib, significant life extension can be achieved with palliative care.
Complications of chemotherapy
Treatment with cytostatics also acts on normal tissue. First of all, fast-growing tissues, such as the mucous membranes of the stomach and intestines, the hematopoietic system in the bone marrow, and hair roots, are affected. Therefore, possible side effects of chemotherapy are nausea, vomiting, diarrhea, hair loss, increased susceptibility to infection, and a tendency to bleed. Side effects can be partially stopped or alleviated with the help of concomitant measures and medications (supportive therapy). As a rule, these side effects disappear after treatment.
The action of radiation therapy is based on the destruction of cancer cells. For cancers of the pancreas, radiation therapy is usually used in combination with chemotherapy (Radiochemotherapy). For locally progressive tumors that cannot be successfully operated on, the so-called neoadjuvant therapy is first performed (this means that combined radiation and chemotherapy is used before a planned operation). In this way, the tumor and the spread of the tumor to the surrounding tissues are reduced. This increases the chance of possible complete removal of the tumor during subsequent surgery. If this succeeds, then the survival rate after 5 years is significantly higher than if the tumor was not completely removed. In addition to shrinking the tumor, radiation therapy is also used to treat symptoms associated with the tumor (such as pain). (palliative therapy).
Along with the previous standard treatment for pancreatic cancer, new methods are constantly being tested that should improve the treatment of this disease. So-called targeted therapies are a new therapeutic approach. They act on different metabolic pathways of the tumor and therefore act specifically on the malignant tissue and largely spare the healthy tissue. Substances from the targeted therapy group, for example, target factors that promote tumor growth, interfere with blood flow to the tumor, or prevent signaling between tumor cells. The tyrosine kinase inhibitor erlotinib is currently the only targeted therapy active that is approved for the treatment of pancreatic cancer.
Tyrosine kinase inhibitor erlotinib
Patients with locally advanced, unresectable, or metastatic pancreatic cancer can be treated in combination with the standard chemotherapy drug gemcitabine and the tyrosine kinase inhibitor erlotinib. Erlotinib targets growth factor attachment sites on the surface of cancer cells. Tumor cells often overproduce these binding sites. When growth factors dock, cells receive a signal for uncontrolled growth. The tyrosine kinase inhibitor Erlotinib interferes with mediated signal transduction from the binding site, due to which the growth of tumor cells is blocked.
Compared with gemcitabine-only chemotherapy, erlotinib treatment may increase survival in patients with locally advanced or metastatic pancreatic cancer
Erlotinib is available as a tablet. The most common side effect of the treatment is acne, which, however, in most cases is only minor and does not require special treatment. It even turned out that the rash is a sign of a very good response to treatment.
Head of the Clinic for General, Visceral and Minimally Invasive Surgery
Head of the Clinic for General, Visceral, Thoracic and Endocrine Surgery
Head of the Clinic for General and Visceral Surgery