Understanding Pancreatic Tumors: What Manohar Parrikar & Steve Jobs fought with dignity

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Several prominent members of the civil society - much loved and respected political leaders, film stars and IT industry pioneers in India and abroad have lately been diagnosed with pancreatic tumors leading to much public interest and headlines on the social media. The dignity and determination with which each one of them faced the disease shall be an inspiration for one and all.

The generic term ‘pancreatic tumors’ includes pancreatic cancers (medically known as pancreatic ductal adenocarcinoma or PDAC), neuroendocrine tumors (NET) and cystic tumors. These tumors differ in terms of investigations and treatment strategies (no surgical intervention i.e. observation for some cystic tumors to major pancreatic resections for cancers and NET). They also differ in biological behaviour and outcomes (NET and cystic tumors often are slow growing and have an indolent behaviour as compared to pancreatic cancer).

For all pancreatic tumors, pancreatic protocol abdominal CT scan with is an essential part of diagnostic work up and may reveal one of the clinical scenarios:

1.      Localized disease (confined to the pancreas and surrounding (regional) lymph nodes):

For patients who are medically fit to undertake major surgery, upfront pancreatic resection (i.e. surgical removal) is the best treatment option that provides chances of long-term survival or cure.

Surgery involves removal of a part of pancreas (depending of tumor location) along with lymph nodes that drain this section of pancreas. Thus, tumors located in the body and tail of pancreas are removed by distal pancreatectomy whereas tumors in the head, neck or uncinate process require a more complex operation - Whipple’s procedure or pancreatoduodenectomy.

There have been several advancements in imaging, surgical techniques and critical care that have made pancreatic surgery more patient friendly and safer (reported mortality of 1-5% for Whipple’s procedure from centres of excellence). Some of the notable recent advances include:

- Increased utilization of laparoscopic / robotic techniques so as to avoid large incisions

- Interventional radiology techniques for management of complications

2.      Locally advanced pancreatic cancer (limited involvement of adjacent major vessels, borderline resectable):

Novel chemo & radiotherapy protocols have been introduced in clinical practice with an intent to downstage such tumors and make them resectable. According to current medical literature, up to 20% of such tumors can now be successfully down staged to undergo curative surgery

3.      Advanced tumors (spread to other organs such as liver, lungs or peritoneum i.e. metastatic) or where curative surgery is not feasible due to serious medical conditions:

In such patients, the aim is to provide good quality of life with multidisciplinary management involving endoscopy, chemotherapy and pain management services. In many patients extended survival is possible.

In summary, for medically fit patients with pancreatic cancer confined to the pancreas, surgery is the best treatment option where long-term survival or cure is feasible. For borderline resectable tumors, successful management protocols for down staging such tumors are available. For patients with metastatic disease, emphasis is on providing good quality of life that may also help extend survival.

Dr Nitin Vashistha
Dr Dinesh Singhal
Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com