Pancreatic Cancer Paper by UEHgm1

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                 Pancreatic Cancer

               By Justin Tennyson
            Anatomy and Physiology II
                   Dr. Gerbec
                  Spring 2008

Dedicated to Carol Tennyson (06/12/30 to 12/18/2006)
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       The pancreas is a small, spongy, grayish-pink colored gland about 12 to 15 cm (6

to 9 inches) long, weighing about 60 grams. It lies deep within the abdomen, its head and

neck in the C-shaped curve of the duodenum, its body extending horizontally behind the

stomach, and its tail touching the spleen. (1) Two different types of glandular tissue

make up the pancreas, one exocrine and one endocrine. The majority of the tissue is

exocrine, set in a compound acinar arrangement. The term acinar comes from a Latin

word meaning “berry”, signifying the grapelike formation of these cells, which release

their secretions into a microscopic duct within each unit. The word compound indicates

that the ducts have branches. These tiny ducts unite to form larger ducts that eventually

join the main pancreatic duct, which extends throughout the length of the gland from its

tail to its head. It empties into the duodenum at the same point as the common bile duct,

that is, the major duodenal papilla. An accessory duct is frequently found extending from

the head of the pancreas into the duodenum, about 2 cm above the major papilla. (1) The

acinar units of the pancreas secrete pancreatic juice. Pancreatic juice contains many

enzymes which aid in the digestion of food. Pancreatic juice is also rich in sodium

hydrogencarbonate which raises the pH of the stomach to enable the enzymes present to

function, and helps to neutralize acid chyme from the stomach.

       Embedded between the exocrine units of the pancreas, lie clusters or “islands” of

endocrine (hormonal) cells called pancreatic islets. Although there are about a million of

these tiny islands, they constitute only about 2% of the total mass of the pancreas. Two

types of specialized cells make up the islets; alpha and beta. They are secreting cells, but

their secretion passes into blood capillaries rather than into ducts. Beta cells secrete
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insulin, a hormone that exerts a major control over carbohydrate metabolism. Alpha cells

secrete glucagon. (1) Interestingly glucagon acts to convert glycogen stored in the liver

to glucose and release it into the blood stream, whereas insulin instructs the body to take

in glucose from the blood during times of satiation, and promotes glycogen storage in the

liver. Thus the two hormones secreted by the pancreas have directly opposite effect on

carbohydrate metabolism.

        Malignant cancer is a tumor (or growth) in which an aggregation of individual

cells begins to grow in a rapid, uncontrolled and abnormal manner; and which may

spread by aggressive local extension or by the seeding of other organs through blood

vessel channels or via the lymphatic system. (2) Benign tumors may also exist, although

are often less serious, and tend not exhibit such rapid growth and metastasis as malignant

tumors. In up to 95% of cases, pancreatic cancer arises from the exocrine portion of the

organ. The least common exocrine cancer comes from the acinar cells. Most of the

exocrine tumors (~90%) are from ductal cells-those which line the pancreatic ducts.

These tumors are classified as carcinomas, a word that refers to tumors arising from a

lining cell. The histological appearance and arrangement of these carcinoma cells appear

as duct-like (or “adeno”) giving the term adenocarcinoma to this most common form of

pancreatic cancer. (2) The majority (~75%) of the exocrine tumors of the pancreas arise

in the head and neck of the pancreas, whereas ~15% occur in the body, and less than 10%

occur in the tail.

        Neuroendocrine tumors of the pancreas (islet cell tumors) may also arise from the

exocrine portion of the pancreas, although are much less common. About 75% of these
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tumors are considered “functioning”. That is they are found to be producing symptoms

related to one or more of the hormone peptides they secrete. (2) The other 25% are

termed non-functioning, as they do not produce symptoms related to the hormones they

secrete. The predominant hormone peptide secreted by the functioning islet cell tumor

renders its name. Islet tumor cells have been found to secrete a multitude of hormonal

peptides; intriguingly some are not even related to the pancreas. This array includes

insulin, gastrin, glucagon, somatostatin, neurotensin, pancreatic polypeptide (“PP),

vasoactive intestinal peptide (“VIP”), growth hormone releasing factor (“GRF”), ACTH

and still others. (2) Non-functioning tumors have been known to produce pancreatic

polypeptide or neurotension, but these hormones do not produce any symptoms, and the

tumor is still categorized as non-functioning.

       The most common functioning pancreatic endocrine tumors are insulinomas,

followed by gastrinomas, glucagonomas and VIPomas. Excess excretion of hormone by

a given functioning tumor typically produces the symptoms which lead to an eventual

diagnosis. Insulinomas, as the name suggests, are islet cell tumors which secrete an

excess of insulin. These tumors often produce symptoms between the ages of 40 and 50,

are seen more often in women, and are typically small tumors. Symptoms produced from

these tumors mimic those seen in diabetics, hypoglycemia being the most common

symptom. Other symptoms can include sweating, tremor and tachycardia, hunger,

nausea, and weight gain. Patients with glucagonomas also commonly present with

symptoms of diabetes and severe dermatitis.
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       Gastrinomas are responsible for over secretion of the hormone gastrin. The

clinical effect of this circumstance is what has come to be called Zollinger-Ellison

syndrome, a triad of signs and symptoms including atypical peptic ulcer disease, gastric

hyperacidity and hyper-secretion, and an associated islet pancreatic tumor. (2) Patients

presenting with these types of tumors are most often males over 60 years of age.

       Cancer, as we now know, is caused by mutations of a gene which confer

abnormal growth potential to cells. Genes in which this potential is directly conferred are

called oncogenes. (2) The genes which act to suppress this phenomenon are called

tumor-suppressing genes. A third type of gene, named DNA-repair gene, can also be

mutated, causing a loss of function and potentially resulting in both oncogenes and

tumor-suppressing genes becoming cancerous. Multiple mutations, resulting in

modification of more than one regulatory pathway, are typically necessary for cancer to

develop.

       An oncogene called K-ras is found to be altered in up to 95% of ductal

adenocarcinomas of the pancreas. Common tumor-suppressor genes which are

inactivated by mutation in this kind of pancreatic cancer are the p53 and p16 genes. (2)

Although these genes are consistently found to be mutated in pancreatic cancer cases,

other mutations have been found, and research is continually ongoing.

       Signs and symptoms of pancreatic cancer often do not develop until the disease

has reached some advanced stages of progression. Moreover, when symptoms do first

develop, they often mimic other disorders such as diabetes, and can commonly be

mistaken as such. When symptoms do appear, they may include:
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       Upper abdominal pain that may radiate to the middle or upper back. Pain is

especially common in more advanced stages of pancreatic cancer. Abdominal pain is a

result of a growing tumor pressing on surrounding organs and nerves. Pain may be

constant or intermittent and is often worse after a meal or when lying down. (3)

       Loss of appetite and unintentional weight loss. Dramatic weight loss in the

absence of diet or exercise is a common sign of pancreatic cancer. Weight loss occurs in

most types of cancer because cancerous (malignant) cells deprive healthy cells of

nutrients, and this is especially true in pancreatic cancer. (3)

       Yellowing of your skin and the whites of your eyes (jaundice). Approximately

50% of people with pancreatic cancer develop jaundice, which occurs when bilirubin, a

breakdown product of worn-out blood cells, accumulates in your blood. Normally,

bilirubin is discarded in bile, a liquid produced by the liver. However, if tumors block

the flow of bile, excess pigment from bilirubin may result in jaundice. Other symptoms

include dark brown urine and white or clay-colored stools. (3)

       Itching. Severe itching may occur in later stages of pancreatic cancer due to the

development of high levels of bile acids accumulating in the skin.

       Nausea and Vomiting. Tumors from advanced cases of pancreatic cancer may

block a portion of the digestive tract, usually the upper portion of your small intestine

(duodenum), leading to nausea and vomiting. (3)

       Digestive Problems. Pancreatic cancer can lead to the inhibition of pancreatic

enzymes from being released into your intestine, making food digestion much more

difficult, especially those foods high in fat. This again may lead to significant weight
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loss, in addition to malnutrition. It’s important to remember that any of the above

symptoms may be caused by cancer, or by any number of less serious illnesses, and the

presence or absence of any of these symptoms does not confirm nor deny pancreatic

cancer. In addition, the above symptoms are general symptoms, most often present with

the most common form of pancreatic cancer adenocarcinoma. The less common forms of

pancreatic cancer, caused from neuroendocrine tumors, may also result in these common

signs and symptoms, but more often mimic effects of the hormone which they over-

secrete.

       The American Joint Committee on Cancer (AJCC) has developed a standardized

way to describe the extent to which pancreatic cancer has spread. This is also known as

the stages of pancreatic cancer, and is the most important factor in choosing treatment

options and predicting a patient’s outlook for survival. The main system used to describe

the stages of pancreatic cancer by The American Joint Committee on Cancer is the TMN

staging system. The system is outlined below. All of the below information can be

found by searching for the American Joint Committee on Cancer, or by simply going on

the American Cancer Society website.

       The TMN system for staging contains 3 key pieces of information:

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.
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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 of letters appear after T, N, and M to provide more details about each of

these factors.

The numbers 0 through 4 indicate increasing severity.

The letter X means “cannot be assessed” because the information is not available.

The letter “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.

       T Categories

TX: The main tumor cannot be assessed.

T0: No evidence of a primary tumor.

Tis: Carcinoma in situ (very few tumors are found at this stage).

T1: The cancer has not spread beyond the pancreas and is smaller than 2 cm (about ¾

inch) across.

T2: The cancer has not spread beyond the pancreas but is larger than 2 cm across.

T3: The cancer has spread from the pancreas to surrounding tissues near the pancreas but

not to blood vessels.

T4: The cancer has extended further beyond the pancreas into nearby large blood vessels.

       N Categories

NX: Regional lymph nodes cannot be assessed.

NO: Regional lymph nodes (lymph nodes near the pancreas) are not involved.
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N1: Cancer has spread to regional lymph nodes.

        M Categories

MX: Spread to distant organs cannot be assessed.

M0: The cancer has not spread to distant lymph nodes (other than those near the

pancreas) or to distant organs such as the liver, lungs, brain, etc…

M1: Distant metastasis is present.

        After the T, N, and M categories of pancreatic cancer have been determined, all

the information is combined in a process known as stage grouping. Stages are assigned

stages by Roman numerals I through IV.

Stage 0 (Tis, NO, MO): 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.

Stage IA (T1, NO, MO): The tumor is confined to the pancreas and is less than 2 cm in

size. It has not spread to nearby lymph nodes or distant sites.

Stage IB (T2, NO, MO): The tumor is confined to the pancreas and is larger than 2 cm in

size. It has not spread to nearby lymph nodes or distant sites.

Stage IIA (T3, NO, MO): The tumor is growing outside the pancreas but not into large

blood vessels. It has not spread to nearby lymph nodes or distant sites.

Stage IIB (T1-3, N1, MO): The tumor is either confined to the pancreas or growing

outside the pancreas but not into nearby large blood vessels. It has spread to nearby

lymph nodes but not distant sites.
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Stage III (T4, Any N, MO): The tumor is growing outside the pancreas into nearby large

blood vessels. It may or may not have spread to nearby lymph nodes. It has not spread to

distant sites.

Stage IV (Any T, Any N, M1): The cancer has spread to distant sites.

        Other factors determine the severity of the cancer, including a grading system G1

to G4, with the G1 cells looking most like normal cells. To determine normality of cells,

they must be analyzed under a microscope.

        The above staging information given is specific for pancreatic cancer; however

the general outline of stages is used by the American Joint Committee of Cancer to

categorize stages of any type of cancer.

        In the United States a total of ~30,000 new cases of pancreatic cancer are

diagnosed each year. However, due to the extreme lethality of the cancer, pancreatic

cancer ranks as the fourth most common cause of cancer death in the United States for

males after cancer of the lung, prostate, and colo-rectum; in females it is also the fourth

most common cause of cancer death after lung, breast and colo-rectum. (5) Male incident

rates in the United States are approximately 40% higher than female rates. Overall the

incident rate of pancreatic cancer is quite low, in fact, pancreatic cancer is quite

uncommon. It is however, a leading cause of cancer death in the United States due to

mortality rates very close to 100%. The pancreas, located in a relatively inaccessible
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location within the abdomen, makes the diagnosis of pancreatic cancer more difficult

than diagnosing other digestive tract cancers, which helps lead to this high mortality rate.

        The National Cancer Institute (NCI) maintains a large national database on

survival statistics for different types of cancer, including pancreatic cancer. The NCI

uses a slightly different staging system when compiling their numbers, grouping cancers

into local, regional or distant stages. (4)

        Overall only 4% of patients will survive more than 5 years after being diagnosed

with pancreatic cancer. For the fewer than 10% of people with pancreatic cancer who are

diagnosed with local disease (cancer that has not spread beyond the pancreas to other

organs), which is likely to be resectable, the 5 year relative survival rate is about 20%. (4)

        For the 1 out of 4 pancreatic cancer patients with regional disease (with spread to

nearby organs and tissues, but no evidence of distant spread) the 5 year relative survival

is about 8%. (4)

        More than half of all pancreatic cancer patients are diagnosed with distant disease,

where the 5 year relative survival is about 2 %. (4)

        Although no one knows for certain what causes pancreatic cancer, research has

shown that people with certain risk factors are more likely than others to develop

pancreatic cancer.

        Studies have found the following risk factors:

Age: The vast majority of pancreatic cancers occur in patients over the age of 60. As

age increases, so does the likelihood for developing pancreatic cancer.
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Smoking: Cigarette smokers are two to three times more likely to develop pancreatic

cancer. Smoking is the greatest risk factor for developing pancreatic cancer, as it has

been associated with one in three cases.

Diabetes: Pancreatic cancer develops more often in patients with abnormal glucose

metabolism than in patients who do not.

Sex: More men than women develop pancreatic cancer.

Race: African Americans are more likely to be diagnosed with pancreatic cancer than

Asians, Hispanics, or Caucasians.

Family History: The risk for developing pancreatic cancer triples if a person’s mother,

father, sister, or brother had the disease. A family history of colon or ovarian cancer has

also been shown to increase the risk of pancreatic cancer.

Obesity: People who are overweight or obese have a greater risk of developing

pancreatic cancer.

Diet: A diet high in animal fats and low in fruits and vegetables increases the risk for

pancreatic cancer. Presumably this risk factor coincides with being obese.

Chronic Pancreatitis: Those who suffer from chronic pancreatitis-a rare genetic condition

marked by recurrent attacks of pancreatitis-are at a greater risk for developing pancreatic

cancer. (Pancreatitis is a painful inflammation of the pancreas.)

Chemical Exposure: Working with petroleum compounds, including gasoline and other

chemicals, increases your risk of developing pancreatic cancer.
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        It’s important to remember pancreatic cancer is relatively uncommon, as such, the

above risk factors are stated due to trends found with patients who have had pancreatic

cancer. Many people with the above risk factors do not get pancreatic cancer. In

addition, some patients with pancreatic cancer have none of these factors. Doctors and

researches still do not know what exactly causes pancreatic cancer, so it is difficult to

prevent. The only prevention methods thus far are to stay away from any risk factors that

can be avoided. Providing healthcare providers with accurate family history reports is

also helpful for early detection and prevention.

        As stated earlier, detecting pancreatic cancer in its early stages is incredibly

difficult. Signs and symptoms typically do not appear until the cancer is large or

metastasis has occurred. The relative position of the pancreas, hidden within the

abdomen, and the rapid spread of pancreatic cancer do not help the issue. Consequently,

researches have focused on finding a reliable screening test for pancreatic cancer. At one

point, scientists believed a substance called CA 19-9 was the answer. CA 19-9 is formed

by pancreatic cancer cells and can be easily detected by a simple blood test.

Unfortunately, by the time the blood levels are high enough to be detected, the cancer is

no longer in its early stages.

        Currently there is no effective screening test for pancreatic cancer, but one or

more of the following may be used to aid in diagnosis:

Physical Exam: Examination of the skin and eyes for jaundice is common, along with

past medical history, abdomen palpation for abnormalities, and ascites.
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Lab Tests: Blood, urine, and stool samples to check for bilirubin and other substances

are often done. Bilirubin is a substance that passes from the liver to the gallbladder to the

intestine. If the common bile duct is blocked by a tumor, the bilirubin cannot pass

normally. (6) Levels of bilirubin in the blood, urine, and stool may become very high as

a result of blockage. High bilirubin levels can also occur from other types of cancer and

some non-cancerous conditions as well.

Computed Tomography (CT) Scan: A CT scan allows visualization of organs, including

the pancreas, in two-dimensional slices. A series of very thin X-rays pass through your

body, which then transmits information obtained to a computer that creates detailed

pictures of your organs and blood vessels. A dye or contrast median may also be injected

into your veins prior to the scan, producing a clearer computer image. Although a CT

scan exposes the patient to more radiation than conventional X-rays, its benefits often

outweigh the risks.

Ultrasonography: Ultrasound devices use sound waves to produce a pattern of echoes as

they bounce off of internal organs. These echoes are transmitted to a computer which

produces the images seen by doctors. The echoes from tumors are different than those

made by healthy tissue. Ultrasound offers a safe, brief, and noninvasive alternative to

detection. Used correctly ultrasound has been shown to detect smaller tumors than are

even found by CT scan. A more invasive ultrasound technique called Endoscopic

Ultrasound may additionally be used for better detection. In this procedure a thin, lighted

endoscope is passed down the patient’s throat, down into the first part of the small

intestine. From there pictures are taken via echoes.
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Magnetic Resonance Imaging: As an alternative to X-rays, this machine uses a powerful

magnetic field and radio waves to create an image of the pancreas.

Endoscopic Retrograde Cholangiopancreatography (ERCP): In this procedure, an

endoscope is passed down the patient’s throat, into the small intestine. A catheter is then

passed through the endoscope into the bile ducts and pancreatic ducts. A dye is injected

from the catheter into the ducts, while simultaneously taking X-ray pictures. This

procedure is typically used to determine whether ducts have been narrowed or blocked by

pancreatic tumors or by some other etiology.

Percutaneous Transhepatic Cholangiography (PTC): PTC is another test used to

determine the etiology of duct blockage. A thin needle is inserted through the skin into

the liver. A dye is then injected through the needle, with X-rays pictures again taken

simultaneously. Unless there is blockage, the dye should move freely through the bile

ducts.

Laparoscopy: This procedure uses a laparoscope to physically view your pancreas and

surrounding tissue with a camera. A small incision is made in your abdomen which the

laparoscope is passed through. In some cases, a doctor may remove some tissue for

biopsy, another detection method. Pathologists will exam the sample under a microscope

to look for cancer cells within the tissue.

         Treatment for pancreatic cancer depends on a multitude of factors. The stage of

the cancer, the age and overall health of the patient, and personal preferences must all be

taken into account. Seeking a second or third opinion on treatment options of pancreatic

cancer is considered wise.
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        The only way to physically remove the cancer is a surgical operation to remove

the tumor. Regrettably, this is only possible with a small percentage of people.

Pancreatic cancer that has spread to other organs, lymph nodes, or blood vessels can no

longer be surgically removed. When surgery is possible, one of the following procedures

is used, depending on the extent and location of the tumor.

Whipple Procedure (Pancreatoduodenectomy): This is the most common procedure used

to treat pancreatic cancer. The Whipple Procedure involves removing the head of the

pancreas. In order to complete this task, the surgeon must also remove the duodenum,

gall bladder, and end of the common bile duct. Parts of the stomach may also need to be

removed, depending on the patient. The remaining bile duct and pancreas are then

connected to your small intestine to allow bile and pancreatic enzymes to continue to

function. Risks of this procedure include internal bleeding and infection.

Total Pancreatectomy: This procedure involves the removal of the entire pancreas, as

well as your bile duct, spleen, gallbladder, part of the stomach and small intestine, and

most of the lymph nodes in the area. The risks often outweigh the benefits in this

procedure, so it is rarely performed. Insulin injections and pancreatic enzymes will need

to be supplied artificially.

Distal Pancreatectomy: This procedure is used primarily to treat islet cell tumors, and

only the distal portion of the pancreas (tail) is removed. In some cases the spleen may

also need to be excised.

        All surgical operations for pancreatic cancer are complex and include risks.
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        Radiation and chemotherapy alone or in combination are alternative treatments to

surgery. If surgery is not possible, they are typically the next line of defense. Radiation

uses high-energy X-rays to destroy cancer cells. (3) Side effects my include a burn on

your skin similar to sunburn where the radiation enters your body, nausea, vomiting, and

fatigue. (3)

        Chemotherapy uses pharmaceuticals to help kill cancer cells. Injected into a vein,

or taken orally, these drugs travel through your blood stream, and are often used to

prevent spread of the cancer. Chemotherapy affects normal cells as well as malignant

ones, especially fast-growing cells in your digestive tract and bone marrow. For that

reason, side effects-including nausea and vomiting, mouth sores, fatigue, and an

increased chance of infection due to decreased leukocytes-are common. (3)

        Emerging therapies and clinical trials offer a chance to expand the knowledge of

medicine, and may be unknowingly beneficial to the patient at the same time. Many

unknowns surround such trials, and the risks should be analyzed completely before

starting a new regimen of any kind.

        Palliative care is another option often taken by pancreatic cancer patients.

Palliative care is more passive in nature, working simply to provide the patient with a

comfortable lifestyle. It does not work to suppress, destroy, or remove any cancer. Some

common palliative care procedures are outlined below:

Surgical Bypass: As stated prior tumors may block the bile duct, pancreatic duct, or

duodenum, causing pain, digestive difficulties, nausea, vomiting, jaundice and severe

itching. Rerouting the flow of bile to bypass the tumor is done.
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Stent Insertion: An alternative to bypass procedure is stent placement. A stent is simply

a tube placed within the bile duct to keep it open.

Pain Management: Tumors in later stages of the disease may press on surrounding

nerves, causing severe pain. Common drugs such as morphine or dilaudid can usually

provide relief, although other options such as cutting nerves that transmit pain signals, or

injecting alcohol into these nerves to block the pain sensation, may be needed.

Pancreatic Enzyme Tablets and Insulin Therapy: By replacing the elements often lost or

reduced during pancreatic cancer, your body’s ability to absorb nutrients and sugar may

increase, reducing diarrhea and weight loss.


      The following case story was taken from Pancreatica.com. The format is
unchanged from the original document.

Walter Leaman Story
December 2005


Walter Leaman lost his courageous battle with pancreatic cancer on October 27, 2006.


Vital Statistics
Walter Leaman was diagnosed in August 2002, at
the age of 59, with Stage IV inoperable
adenocarcinoma . His prognosis was approximately
6-8 weeks to live. Treatment was clinical trial
chemotherapies: Gemzar/Cisplatin; later
Gemzar/Oxaliplatin. Care was received at the
University of California at San Francisco, which has
an NCI-designated Comprehensive Cancer Center.
His oncologist was department head Dr. Margaret
Tempero. Walter's primary caregiver, his wife Jean
Leaman, also contributed to this story.
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Background
Walter and Jean live in Danville, California, about 30 miles east of San Francisco, where
they own and operate a family business. They have three grown children, one of whom -
along with her husband and a grandchild - lived with them during the period of this
diagnosis and treatment.

Medical Journey - Diagnosis
In the spring of 2002, stomach problems first sent Walter to their long-time general
practitioner. The next four months were spent pursuing the prevailing theory of a
developing ulcer. At that point, a second consult with GP Dr. Lowell Kleinman led to an
endoscopy and biopsy. When those were negative, he ultimately recommending
exploratory surgery to ascertain the precise problem.

The surgeon was a highly rated one, although not a pancreatic cancer specialist. The
morning after the surgery, he arrived in Walter's hospital room, in near-dawn-darkness, to
announce: "We were hoping we would find lymphoma, but we didn't. I'm so sorry to tell
you that you have Stage IV pancreatic cancer. It has spread to your stomach and your
liver, there is some lymph node involvement, and I'm so sorry there's nothing we can do
for you." Then, with tears in his eyes, he left Walter - quite literally - in the dark.

The laparoscopic surgery had indicated a large mass protruding from the body of the
pancreas and adhering to the posterior wall of the stomach. Lesions, also biopsied as
malignant, were present in the liver as well. In a separate conversation with Jean, the
surgeon predicted that her husband probably had about six to eight weeks to live.

Walter's mind was a blur. "How could I go from having a little stomach pain to dying,
this fast?" Jean had a somewhat different reaction. During the long waiting period, she
had been on the web doing endless research, and had actually come to the conclusion -
from the symptoms and the location of the pain - that it just might involve the pancreas.
When she mentioned that possibility to the gastroenterologist doing the earlier
endoscopy, he was dismissive. "But when the diagnosis finally came through," says Jean,
"I wasn't surprised."

Both describe the next couple of weeks as a surreal transition stage - "a grieving process".
But as with many couples, they differed in their overall reactions to the news. Asked for a
word to describe his feeling then, Walter says "resignation". Jean says "fighting-back".
Walter started writing down instructions for cleaning the pool filter. Jean started
shopping for hope.

Next stop was the San Ramon Regional Medical Center, where they met with head
oncologist Dr. Peter Wong. The Leamans' goal by then was modest - to get a firmer
prognosis on the number of weeks left. To their surprise, Dr. Wong had a different goal.
"I want to have Walter back playing golf within a year." It was the first positive thing
either had heard since this dire diagnosis, and tears - and possibilities - began to flow.
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Dr. Wong was aware of some clinical trials being conducted by a colleague, Dr. Margaret
Tempero, head of oncology at the University of California San Francisco (and member of
Pancreatica.org's Science Board). "If anyone can help you, she can," said Dr. Wong.
Fortuitously, a particularly promising trial was about to start. It involved two drugs now
common in cancer treatment: Gemzar and Cisplatin.

Medical Journey - Treatment
And as the life-giving chemo began, Walter started feeling some hope for the first time.
But most friends and family, knowing little about this disease and all of it bad, were
(despite best intentions) not exactly surrounding them with encouragement. By the time
the trial began, Walter was in serious back and stomach pain and had lost a total of 50
pounds. "It was no surprise to anyone who saw me that I was very near death." They
know many of their friends were feeling they were in denial. Even three years out, "some
probably still do".

By the end of the first three weeks, nausea, smell-sensitivity and balance problems had
entered the picture. But Walter's pain and other symptoms were subsiding, eating was
getting easier, and the positive vibes were increasing.

Recovery
Walter did not experience some of the Whipple-specific dietary problems, since he did
not qualify for that procedure. However the disease, combined with the effects of the
chemo, did make him disinterested in eating at some points. "It's not the chemo that kills
you, or the cancer, but that you starve yourself to death." During those periods, Jean had
to force eating, and sometimes resort to tough love: "You can eat here, or you can go
back to the hospital and get an IV. And trust me, they won't be as nice about it as I am…"

Visualization played a helpful role at times. During chemo, Walter would sometimes
imagine his chemo infusions as a group of ducks, cleaning up the cancer cells by going
around the edge of ponds, as he'd often seen them do. At other times, he experienced
some relief when he focused all his healing energy, once as his grandson, then later his
cat, instinctively rubbed/kneaded his stomach. "I'll never know for sure what worked, but
I'm giving them all the credit they deserve just for trying!"

In communicating about Walter's situation with their young grandchildren - especially the
one that lived with them - they kept it simple. Grandpa's sick, and we're all trying to help
him get better.

"Cancer Free!" In January 2004, 16 months after the terminal diagnosis, Walter and Jean
heard the words they never expected to hear. That was the good news. The bad news was
that, as often happens, the relentless impact of the Cisplatin had seriously affected his
kidneys. The prospect of dialysis loomed, and Walter had a dilemma. He was in
uncharted territory - the chemo regimen was keeping him alive, but what would happen
when it stopped? Doctors advised him that, at this point, the kidneys were more likely to
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kill him than the original problem. So, chemotherapy ceased and bimonthly CT scans
continued.

15 months passed. Then in the spring of 2005 a tumor reappeared, this time on Walter's
adrenal gland. Dr. Tempero resumed treatment, this time pairing Gemzar withOxaliplatin,
another now-common cancer drug then in trials. Incredibly, the tumor again responded.
By the fall of 2005, it was gone again - with no further recurrence so far.

So Walter remains in watch-and-see mode, with CT scans continuing every 60 days. "By
now, I glow in the dark," he says. But two side effects are with him as well. First, a new
but not-uncommon one, peripheral neuropathy - an ongoing numbness in the fingers and
toes. Second, the damage to the kidneys makes it dangerous to use the standard "IV
Contrast" which helps to provide clear readings on the all-important CT scans. So while
they think things look good, it's difficult to be sure… A nephrologist is now stabilizing
the Creatinin levels, and is recommending the use of a "kidney coating" medication
(Mucomyst) that may permit the full (contrast-enabled) CT scans to resume.

"This illustrates one of the unique problems with people who beat the odds, probably
with any disease," Jean observes. "The medical community doesn't quite know what to do
with you next. The clinical trial saved you. But it caused other problems. And since
you're the rare exception, there are no known solutions yet, in many cases, to those new
problems."

       In conclusion, pancreatic cancer is a very serious cancer, giving it the position of

the fourth deadliest cancer today. It develops from cancerous cells form in the tissues of

the pancreas, a large organ responsible for carbohydrate metabolism. Pancreatic cancer

spreads swiftly, consuming nearby organs, lymph nodes, and blood vessels. Signs and

symptoms often do not appear until after the disease is advanced, and surgical removal is

no longer possible.

       Pancreatic cancer still remains an illusive cancer, but advances in current

medicine provide new answers everyday. Certain risk factors for the development of

pancreatic cancer have been identified, with smoking being the greatest risk factor. In

addition, common genetic mutations have been identified, sparking new innovative

research focusing on restoring these mutations.
                                                                               Tennyson 22

       Due to the “hidden” location of the pancreas, detection methods are not full proof,

making catching the disease at an early stage even more complicated.

       Finally, new procedures are continually being fabricated to further the life span of

those diagnosed with pancreatic cancer. However, despite the current advances in

medicine, a grim 5 year survival period exists for those with pancreatic cancer. In fact,

palliative caredesigned simply to comfort the patient is often the best option. If

diagnosed with pancreatic cancer, coming to terms with your disease is necessary.
                                                                      Tennyson 23

                                  References

1) Thibodeau, Gary A. “Pancreas.” Anatomy and Physiology. Mosby Elsevier:
   Missouri, 2007. 947-949.

2) “Pancreatic Cancer Frequently Asked Questions.” 2008. www.pancreatica.org

3) Mayo Clinic Staff. “Pancreatic Cancer.” 12 Apr 2006.
   www.mayoclinic.com/print/pancreatic-cancer/DS00357/DSECTION=1

4) “How is Cancer of the Pancreas Staged.” 12 Mar 2007. American Cancer
   Society. www.cancer.org

5) Lowenfels, Albert B. and Maisonneuve, Patrick. “Epidemiology and Prevention
   of Pancreatic Cancer.” Journal of Oncology 2004. 34(5) 238-244.

6) “Cancer of the Pancreas.” National Cancer Institute. NIH Publication No. 01-
   1560. www.cancer.gov

7) Hezel, Aram F. “Genetics and Biology of Pancreatic Ductal Adenocarcinoma.”
   Genes and Development v.20 no.10. (2006): 1218-49

8) Freelove, Robert. “Pancreatic Cancer: Diagnosis and Management.” American
   Family Physician. v.73 no.3 (2006): 485-92.

9) Brender, Erin. “Pancreatic Cancer.” Journal of the American Medical
   Association. vol.297 no. 3 (2007)


10) Bardeesy, N. and DePinho, R. “Pancreatic Cancer: Making Progress.” Nature
    Reviews. (2002): 897-909

								
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