Cancer of the pancreas occurs when pancreatic cells begin to multiply out of control resulting in the formation of a mass or tumour.
Dr. Emmanuel Enabulele
Lately, we have been navigating through the anatomical zone often referred to as the embryological foregut. In the course of this, we touched on the inflammatory conditions of the gallbladder and the closely related pancreas. We were considering doing something about the so-called Carcinoma of the head of pancreas and its relevant to public health when the news of the harvest death hit us from abroad. The first was the legendary music icon, Aretha Franklin, who had succumbed to cancer of the pancreas. Then our very own Koffi Anan, the best diplomat to come out of continent from natural causes and then the America patriot, John McCain, who ran against Barack Obama in 2008 on the platform of the Republican Party. He had succumbed to GLIOMA, a malignant condition involving the glial cells of the brain whose function is mainly as a connective tissue.
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Glial cells are not neurons. It suddenly dawn on us that even though we might not notice it, demographics are changing all over the world and that back home the population of senior citizens are increasing. This brings to the fore with time the prevalent of neoplastic conditions would increase. This would of course, be in addition to organic non-communicable conditions like diabetes mellitus and hypertension.
So we got convinced that cancer of the pancreas was what a mention.
For a recap, the pancreas is a glandular organ that is located behind the stomach in the first part of the intestine known as the duodenum in its ‘C-Shape’ curvature. It has both exocrine and endocrine functions. As an exocrine organ it produces and secretes digestive enzymes that are delivered into the duodenum through a duct system that includes the bile and the hepatic ducts. Its endocrine function involves the production and release of insulin and glucagon hormones directly into the blood for the regulation of blood sugar levels.
Cancer of the pancreas occurs when pancreatic cells begin to multiply out of control resulting in the formation of a mass or tumour. These cancerous cells have innate ability to spread to other organs of the body where they are injurious to them. This process is known as metastases. There are different types of pancreatic cancer depending on their cell of origin. The commonest type is the adenocarcinoma, which accounts for more than 80 percent of all the cases of pancreatic cancer. The adenocarcinoma tumors as a rule start within the exocrine portion of the gland that produces digestive enzymes. There are other types of non-adenocarcinoma tumours that may also arise from these cells. The second time cancer of the pancreas is that derived from the neuroendocrine portion of the pancreas, which produces hormones. Sometimes they are referred to as Islet cells tumour.
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One of the bad news about this lesion is that usually there are NO symptoms during the early stages of the disease; and symptoms specific enough to indicate the occurrence of this cancer typically do not develop until very late in the disease, and by this time the disease must have spread. Thus late diagnosis is almost a normal feature of this disease. Generally signs and symptoms of pancreatic cancer would include yellow discolouration of the sclera of the eyes, abdominal pains, back pains, and light coloured stools dark urine and progressive loss of appetite. Most of the symptoms result from the tumour compressing neighbouring structures in the process interfering with their functions. This leads jaundice and attendant dark urine. The back pain usually is a referred one found in most pancreatic lesions including penetrating peptic ulcer disease.
There is usually weight loss, which can be very marked in the advanced form of the condition. This is attributable due to indigestion from enzymatic activity failure and loss of appetite and nausea.
In pancreatic cancer bowel habits maybe adversely affected and this would manifest as fatty foul smelling faeces that is difficult to flush away in toilet closet and chronic constipation. In terms of incidence more than half of those with adenocarcinoma of the pancreas would present with features of diabetes mellitus. This is in contradistinction to the neuro-endocrine variant of pancreatic tumor that may be secreting excessive insulin by the Islet cells. This tumor is often referred to as INSULINOMA. Here low blood sugar levels in the blood known, as hypoglycaemia is a real challenge.
The Diagnosis of Pancreatic carcinoma is based on sound clinical history and assessment with a high index of suspicion. The most common symptom is unexplained weight loss especially after the
age of 40 years. In terms of prevalence the age bracket of maximum incidence is 70. Some patients would develop atypical type II diabetes that is difficult to control. A recent attack of pancreatitis may be an indicator. Usually, an experienced caregiver would think of pancreatic carcinoma when there is persistent abdominal pain or back pain, indigestion and fatty faeces.
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Clinically, a painlessly swollen gallbladder known as Courvoisier’s sign can raise the index of suspicion and help to differentiate pancreatic cancer from gallstones or caholelithiasis.
For completion of diagnosis medical imaging techniques are often employed. Computerised tomography (CT scan) and endoscopic ultrasound are used both to confirm the diagnosis and help to whether the tumor can be surgically removed or resected. Magnetic resonance imaging may also be used n some cases together with cholangiopancreaticography. Ironically, the popular abdominal ultrasound is not very sensitive in the diagnosis of pancreatic cancer and can miss small tumors. However, it can be used to identify spread to the liver and assess the attendant fluid collection in the abdomen known as ascitis. In practice, it is usually the first and cheap examination carried out before other sensitive imaging techniques.
A fine needle aspiration, often guided by endoscopic ultrasound could be used to obtain a specimen for histology when in doubt. This is usually not a compulsory prerequisite in the management of cancer of the pancreas. However, the commonest form of pancreatic adenocarcinoma is typically characterised by moderately to poorly differentiated glandular structures on microscopic examination. The ground substance of this tumour is dense with scar or fibrous tissue.
• To be continued.
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Already 60
As I was busy trying to meet the deadline for this write up, my phone was abuzz and my Facebook account very busy. I was joyfully reminded that I have joined the senior citizens club at a low rank of 60.
I am happy to be here. Some have asked about the drinks and chopinto. My humble response is: I neither count milestones nor moments but how many lives I have touched with my surgical knife and education here.
Love you all for the felicitations.