CANCER OF PANCRES

PRESENTED BY-
MS. EKATA SINGH
NURSING TUTOR
OBSTETRIC & GYNEACOLOGY

NURSING
 INTRODUCTION

Pancreatic cancer originates from uncontrollable growth of pancreatic cell

because of abnormal gene mutations. It develops from two types of
pancreatic cells that are:
(1) Exocrine cells and
(2) Neuroendocrine cells such as islet cells.
 Most of the pancreatic cancer arises from exocrine cells and usually
detected in later stages. Neuroendocrine tumors of pancreas are less
common but they are more easily treatable as compared to exocrine tumor.
 Approximately, 70% of tumors originate from head and neck of pancreas,
20% from body, and 10% arises from tail.
 DEFINITION

Pancreatic cancer refers to malignancy

of pancreas in which uncontrollable
malignant cells develop in the tissues
of pancreas. It may spread directly to
nearby organs such as liver, small
intestine, and spleen or it may spread
through blood or lymphatic system to
distant organs or lymph nodes.
 EPIDEMIOLOGY AND INCIDENC

 In 2018, 458,918 cases of pancreatic cancer have been diagnosed

worldwide and 355,317 new cases are estimated to occur till 2040.
 Worldwide, pancreatic cancer is the 7th leading cause of cancer
associated to death and ranked 14th in incidence.
 Its incidence is more among males than females because of habits of
smoking and alcoholism. The occurrence rate of pancreatic cancer is
more in developed countries.
 ETIOLOGY AND RISK FACTORS

 Age, gender, and ethnicity

 Heredity-family history of genetic syndrome
 Cigarette smoking
 Alcohol consumption
 Obesity
 Diet
 Infections
 Exposure to chemicals
 Chronic pancreatitis
 Diabetes mellitus
 TYPES OF PANCREATIC CANCER

1. Exocrine tumors

2. Endocrine turnors
 CONT…

1.EXOCRINE TUMORS: Exocrine

tumors are the most common type of
pancreatic cancer. They develop when
cells of exocrine glands start to
develop uncontrollably. Normally,
these exocrine cells secrete the
pancreatic enzymes into the small
intestine for digestion of food.
 CONT….

2.PANCREATIC NEUROENDOCRINE
CARCINOMA: Pancreatic neuroendocrine
tumors are rare type of pancreatic cancer.
They develop from the cell of endocrine
glands that secretes hormones such as insulin
and glucagon into blood, i.e.. islet cells of
pancreas that is why they are also known as
islet cell tumors.
 TYPES OF EXOCRINE TUMORS
 Adenocarcinoma: Pancreatic adenocarcinomas are the most
common type of exocrine tumor. About 85-90% of exocrine tumors
are the adenocarcinomas and mostly they grow in the head of
pancreas. Most of these adenocarcinomas arise from the pancreatic
duct and also known as pancreatic ductal carcinoma (PDAC)

 Acinar cell carcinoma: In rare cases, the cancer develops from the
cells that make the pancreatic enzymes, and they are known as
acinar cell carcinomas. Acinar cell carcinoma accounts for 5% of
exocrine pancreatic cancer.
CONT…..

 Intraductal papillary mucinous neoplasm (IPMN): These

tumors are formulated inside the pancreatic duct and they release
thick mucus called mucin that causes ductal obstruction. IPMN
tumors are not cancerous from their origin but might become
cancerous if not treated at the early stage .
 TYPES OF PANCREATIC
NEUROENDOCRINE CARCINOMA
 Gastrinoma (Zollinger-Ellison syndrome):
Gastronomas are highly malignant and found in pancreatic head. They secret
the gastrin. Too much level of gastrin to condition known as Zollinger -
Ellison syndrome Incidence is higher among males and patients with multiple
peptic ulcers.
 Glucaganoma (glucagon): It is a rare type of pancreatic neuroendocrine
tumor. Glucagonomas produce glucagon. The most common site for
glucaganoma body of pancreas. These tumors are very large in size and
easily spread to other parts of body.
 CONT….

 Insulinoma (insulin): These tumors release insulin. Insulinomas

tumors are smaller in size and difficult to diagnose. These tumors are
well-circumscribed and equally distributed throughout the pancreas.

 Somatostatinoma: Somatostatinoma are the tumors that produce

somatostatin. They can grow in any part of pancreas or duodenum.
Somatostatinoma are rare type of tumors. They are very large in size
with more chances to become malignant.
 CONT…..

 Nonfunctional islet cell tumor: These types of tumors do not release

any hormone and are mostly malignant in nature.
 STAGES

 Stage 1: Cancer is limited to pancreas itself.

 Stage II: Cancer moves to other nearby organs of body such as
intestine, without spread to lymph nodes.
 Stage III: Cancer spread to lymph nodes.
 Stage IVA: In this stage, tumor spread to other parts of body such
as stomach, gallbladder, but no involvement of distant organs
 Stage IVR: It is a severe stage of pancreatic cancer in which
cancerous cell spread to distant organs of body.
 Recurrent: In this stage, cancer develops recurrently even after full
treatment.
 CONT….

There are three stages of islets cell cancer:

1. Involving single site of pancreas

2. Cancer growing in different areas of pancreas
3. Cancer that spread to other organs through lymph nodes
 Tumor, Node, Metastasis Stages of Pancreatic Cancer
T (Tumor)
 TX: Primary tumor that is small in size and is not diagnosed.
 TO: Absence of pancreatic cancer.
 Tis: Carcinoma is benign.
 T1: Tumor is limited to pancreas and size is up to 2 cm.
 T2: In this, tumor is only in pancreas and ranges from 3 to 4 cm.
 T3: Size of tumor is >4 cm and extends beyond pancreas without spread to blood
vessels.
 T4: Tumor extends to other organs including arteries and veins nearby pancreas.
 N (Node)

 NX: No evidence of cancer in regional lymph nodes.

 NO: Not involvement of regional lymph nodes.
 NI: Cancer metastasizes to three lymph nodes.
 N2: Involvement of more than three lymph nodes.
 (M) Metastasis

 Mo: Tumor does not move to other organs.

 M1: Cancer spread to other organs of body including distant lymph
nodes.
 PATHOPHYSIOLOGY OF PANCREATIC
CANCER
Pancreatic cancer metastasizes to regional lymph nodes. liver, and to the lungs.

Directly invade surrounding visceral organs such as the duodenum, stomach, and colon

Metastasize to any surface in the peritoneal and abdominal cavity

Ascites

Painful nodular metastases on skin Metastasis to bone Spreads to the brain

 CLINICAL MANIFESTATIONS
 Pain in abdomen
 Abdominal bloating
 Jaundice
 Nausea/vomiting
 Anorexia and indigestion
 Weight loss
 Hepatomegaly
 High blood sugar level or diabetes
 Deep vein thrombosis
 Pulmonary embolism
PANCREATIC NEUROENDOCRINE TUMOR

Gastrinomas:
 Stomach ulcers
 Nausea
 Loss of appetite
 Ulcers can bleed leading to anemia
 Feeling tired
 Shortness of breath
 Black and tarry stool
Glucagonomas

 Excessive thirst or polydipsia

 Excessive urination or polyuria
 Excessive hunger or polyphagia
 Diarrhea
 Weight loss and malnutrition
Insulinomas

 Weakness
 Confusion
 Sweating
 Tachycardia
 Seizures
Somatostatinomas

 Abdominal pain
 Nausea
 Anorexia
 Weight loss
 Diarrhea
 Jaundice
 DIAGNOSTIC EVALUATION

 History collection and physical examination

 Palpation of abdomen
BLOOD TEST
 Tumor marker-CA 19-9 and carcinoembryonic antigen
 Liver function test
 CBC
 RFT
 Coagulation profile
 CONT….

IMAGING TESTS
 CT Scan
 Biopsy
 MRI
 Abdominal Ultrasound
 Endoscopic retrograde cholangiography
 Percutaneous transhepatic cholangiography
 Positron emission tomography
 MANAGEMENT
 Borderline respectable: Use of
neoadjuvant therapy and then
surgery.
 Unrespectable: Treated with
chemotherapy or chemo –radiation.
 Metastatic diseases: Use of
chemotherapy or other palliative
treatments.
 SURGICAL MANAGEMENT

Whipple procedure: In Whipple

procedure, head of pancreas, portion of
stomach, bile duct, duodenum, and
gallbladder are surgically removed. After
this removal remaining structures such as
part of pancreas, stomach, and bile duct is
reconnected to intestine to facilitate the
flow of digestive secretions directly into
intestine .
 CONT….

Distal Pancreatectomy: In distal

Pancreatectomy only tail of
pancreas is resected with
preservation of other parts of
pancreas .
 CONT……

 Total Pancreatectomy: Total

Pancreatectomy procedure is
done in severe cases in which
entire pancreas is removed
along with spleen .
 CHEMOTHERAPY

 The patients are administered chemotherapeutic drugs IV or orally.

 These drugs are either given alone or may be combination of several

drugs.

 The drugs approved for pancreatic cancer are: oxaliplatin, 5-fluorouracil,

gemcitabine and Irinotacken.
 ADJUVANT THERAPY

 Adjuvant therapy with gemcitabine is now accepted as standard therapy

for surgically resected pancreatic cancer
Adjuvant chemotherapy regimen:
 Gemcitabine 1000mg /m² IV over 30 minutes weekly for 3 weeks, every
4 weeks for six cycles.
 mFOLFIRINOX: Oxaliplatin 85mg /m² , leucovorin 400 mg /m²,
irinotecan 150mg/m²,5-FU 2.4 g/m² over 46 hours every 14 days for 12
cycles.
 CONT….
Adjuvant chemotherapy and chemoradiation:
 Concurrent chemoradiation starting 1-2 weeks after gemcitabine, 5-
fluorouracil (FU) 250mg /m²/day continuous IV infusion via pump
during radiation.
Treatment recommendations for locally advanced, unresectable
disease:
 Gemcitabine 1000mg /m² IV over 30 minutes weekly for 3 weeks;
every 28 days
 5-FU 500 mg/m²/day IV bolus on days 1-3 and 29-31with concurrent
radiotherapy.
 CONT….

Treatment recommendations for metastatic disease

 Gemcitabine 1000 mg / m² IV over 30 minutes weekly for 7 weeks,
followed by 1 week off, then weekly for 3 weeks; every 28 days.
 Gemcitabine 1000 mg /m² IV weekly for 3 weeks, every 28 days,
plus capecitabine 1,660mg / m²/ day weekly for 3 weeks; every 28
days.
 NEOADJUVANT THERAPY

Neoadjuvant therapy for patients with resectable or borderline

resectable tumor.
 FOLFIRINOX, with or without subsequent chemoradiation.
 Gemcitabine + albumin-bound paclitaxel, with or without subsequent
chemoradiation.
 Gemcitabine + cisplatin >= 2 - 6 cycles) followed by chemoradiation
(only for known BRCA1/2 mutations).
 RADIATION THERAPY

Radiation therapy is also known as radiotherapy. It involves the uses of high

energy X-rays to kill cancer cells. External beam radiation therapy is the
most common therapy used for pancreatic cancer. In this, radiations are given
externally from machine to affected area. There are different methods of
radiation therapy for pancreatic cancer:
 Conventional or traditional radiation therapy: In traditional radiation
therapy, low dose of radiation per fraction are given on a daily basis.
Treatment is usually given for 5-6 weeks.
 CONT….

 Cyberknife or stereotactic body radiation therapy (SBRT): Cyberknife

is a new approach of radiation therapy. It is a form of shorter treatment. It
uses high dose of radiations that are given over 5 days.

 Proton beam therapy: Proton beam therapy is also a form of external

beam radiation therapy but it uses the protons instead of X-rays. It is
effective therapy that causes less health issues. Combination of these two
therapies helps in shrinkage of tumor that is further removed by surgery.
 IMMUNOTHERAPY

 Immunotherapy is also known as biologic therapy. It is used strengthen

the immune system. It uses the materials either made up from body or in
laboratory to improve the function of body's immune system. For
pancreatic cancer anti-PD-1 antibodies like dostarlimab and
pembrolizumab are used.
 TARGETED THERAPY

Target therapy uses the drugs that kill cancer genes or proteins top cancer
cell growths. This therapy helps to block the growth or spread of cancer cells
with limited damage to healthy tissues. The most commonly used drugs are:
 EGRF (epidermal growth factor receptor) inhibitors: These are those
drugs that act over cancer cell protein, which further inhibit growth of
cancer cell.
 CONT……
 PARP (poly-ADP ribose polymerase) inhibitors: Olaparib or Lynparza
is a commonly used PARP inhibitor. PARP is an enzyme that helps in
combination with BRCA gene to repair damage cancer cell
deoxyribonucleic acid (DNA). By blocking PARP pathways, it is
difficult to repair damage DNA of tumor cell that further leads to death
of cancer cell.
 NTRK (neurotrophic tyrosine receptor kinase)inhibitors: Changes
in NTRK genes sometimes act as a cause for growth of pancreatic tumor.
NTRK inhibitors such as larotrectinib act over protein made by NTRK
gene.
 PALLIATIVE SURGERY

If the cancer cannot be removed or has spread throughout the body then
palliative surgery is used to treat symptoms and to improve survival of
client.
 Biliary bypass: This procedure is used if cancer cause blockage of
common bile duct. In biliary bypass surgeon remove the area of blockage
and connect it with duodenum to create new pathway.
 CONT…..
 Endoscopic stent placement: Stent placement is also used to treat
blockage of bile duct. In this procedure, a catheter is used to place stent into
blocked area which helps to relieve blockage and improve flow of bile into
small intestine.
 Gastric bypass: If tumor size is very large that is causing blockage in
passing of food content into small intestine then gastric bypass surgery is
performed. During this operation stomach is directly connect to small
intestine to bypass blockage.
 NURSING DIAGNOSIS

 Acute pain related to abnormal growth of pancreatic cell as evidence by

facial expression.
 Risk for fluid volume deficit related to fluid loss associated with
vomiting and diarrhea.
 Imbalance nutrition status less than body requirement related to anorexia
as evidence by weight loss.
 Risk of impaired mucosal lining of mouth related to adverse effect of
chemotherapeutic drugs.
 Risk of impaired skin integrity related to high dose of radiation therapy.