Staging
The stage of a malignant disease describes how much disease appears to be present. The stage of a cancer is important for selecting appropriate treatment and providing information about life expectancy and outcomes.
Pancreatic cancer is staged according to international guidelines which assess the size and extent of a tumor, involvement of lymph nodes and spread to distant sites.
Stage 0: Cancerous cells are found in the duct of the pancreas but have not penetrated the surrounding tissue. This is also known as carcinoma in situ.
Stage I: Cancer is confined to the pancreas. In stage IA, the tumor is smaller than 2 cm in greatest dimension. In stage IB, the tumor is greater than 2 cm.
Stage II: Cancer has extended beyond the pancreas locally. In stage IIA, cancer may be penetrating tissues and organs adjacent to the pancreas but does not involve the lymph nodes. In Stage IIB the cancer has spread to local lymph nodes and may also be locally invasive to nearby tissues and organs.
Stage III: Cancer has invaded or involves two major branches off of the aorta, the celiac axis and the superior mesenteric artery. Node involvement may or may not be present.
Stage IV: Cancer has spread to a distant site such as the lungs or liver.
Patients with Stage I or II are conventionally considered potentially “resectable,” which means a surgery may be performed to remove all of the detectable tumor without damage to important structures such as the main blood vessels to the gastrointestinal tract. It also means that there is no evidence the disease has spread to other organs.
Select patients with Stage III disease may be considered for resection after initial treatment with chemotherapy and radiation. We call this the Borderline Resectable category. However, not all patients with Stage III disease are resectable, and we call this the Locally Advanced category.
In patients with Stage IV disease the spread of the disease is such that surgery for cure is not possible. Chemotherapy is the mainstay of treatment in these patients.
Treatment
Once the diagnosis has been confirmed and the stage of cancer determined, your team of specialists use this information to develop a treatment plan that is specific to your stage of cancer and your overall health. Treatment of pancreatic cancer at Orlando Health Cancer Institute consists of three types of therapy:
- Chemotherapy
- Radiation
- Surgery
For every patient, a multidisciplinary team made up of medical oncologists, surgical oncologists, and radiation oncologists review the tests and imaging to develop recommendations on an individual basis. When possible, this personalized treatment plan will include all three types of therapy, depending on the type of tumor, its stage, and the patient’s overall state of health.
Surgical resection of the tumor, when possible, is the only treatment that offers a chance of cure for pancreatic cancer. The type of resection depends on the location and nature of the tumor. Operations performed include pancreaticoduodenectomy (the Whipple operation) and distal pancreatectomy. These operations are complex and have a significant chance of complications and also may have a significant impact on a patient’s quality of life. One important aspect of treatment for pancreatic cancer, therefore, is having an experienced team helping patients through this difficult time.
Chemotherapy
Chemotherapy is the use of medications to kill cancer cells. It may be administered to the patient through a vein (intravenously), in the muscle (intramuscular), or by mouth. Chemotherapy is often used in addition to surgery radiation therapy.
There are several combinations and schedules used in the treatment of pancreatic cancer. The simplest employ single agents, specifically 5-fluorouracil or gemcitabine. At UF Health Cancer Center - Orlando Health we also use combinations of agents (regimens) to more effectively treat both primary tumors and metastatic disease. One is a doublet regimen using gemcitabine and nab-paclitaxel. Another is a triplet regimen using 5-fluorouracil, oxaliplatin, and irinotecan. Such combination regimens are more aggressive and have been demonstrated to be more effective at prolonging survival.
Whether treatment consists of single or multiple agents, chemotherapy is given in a series of scheduled doses over a given amount of time called cycles. A cycle may take two to four weeks to complete. Depending on the overall treatment plan, typically several cycles are required to consider the treatment complete. Depending on the situation, we may recommend additional cycles of chemotherapy.
The choice of treatment regimens is determined by how our medical oncologists feel that individual patients will tolerate the side effects of a given regimen. Our team works closely with our patients to provide symptom management and monitor for severe side effects. Sometimes, adjustments in dosing and scheduling are required to accommodate individual patient needs.
Most chemotherapy is delivered directly into the veins. Typically, patients come to our infusion centers and have labs drawn, receive fluids and supportive medications and chemotherapy during the course of a few hours. Sometimes, depending on the regimen, a pump may be provided to continue an infusion over several days at home. Your chemotherapy nurses provide teaching and support throughout the process and will often coordinate with home health nurses to provide additional support and monitoring.
In order to avoid damage to veins in the arms, chemotherapy is typically administered through an infusion port, which is a reservoir implanted beneath the skin and attached to a catheter inserted into the larger veins of the chest and neck. The port is accessed for lab draws, fluid administration, and for chemotherapy. It is then de-accessed when not in use. Your nurses will also give instruction and support on how to maintain the ports.
Radiation
Radiation therapy is performed by a radiation oncologist who uses high-energy rays such as X-rays to kill or shrink cancer cells. Radiation is delivered externally from a machine outside the body and can be refined to minimize the effect on other organs.
Radiation can be an important part of treatment for pancreatic cancer. Specifically, when patients have disease that is locally advanced or unresectable, radiation may be used to treat the tumor, especially if it is causing pain or other symptoms.
At Orlando Health Cancer Institute, we also use radiation after surgery to provide additional treatment of the area around the tumor. Lymph nodes in the area may also be treated in case cancer cells are present in them.
For patients with Borderline Resectable disease, we use radiation to treat the tumor prior to surgery. In some patients, this helps us get them to surgery and clear the disease. Several trials are also available examining the use of proton therapy for pancreatic cancer.
Surgery
The Whipple operation, formally called a pancreaticoduodenectomy, is performed for tumors in the head of the pancreas. It involves removal of the head of the pancreas, the gallbladder and a part of the common bile duct. It also involves removal of a portion of the stomach (a “Classic Whipple”). Sometimes it is possible to perform the operation and preserve the stomach, an operation called a pylorus-preserving pancreaticoduodenectomy (also known as a pylorus-sparing Whipple and “mini-Whipple”). Connections are then made to the pancreatic duct, bile duct, and stomach in order to reconstruct the gastrointestinal tract.
This operation takes from four to eight hours to perform, and requires a hospital stay between seven and 14 days. Typically, patients continue to recover from surgery over the course of four to six weeks.
Orlando Health Cancer Institute is considered a high volume center for this operation, with low mortality rate of two percent and superior outcomes.
Distal Pancreatectomy: Tumors in the body and tail of the pancreas are removed by removing the body and tail of the pancreas in an operation called a distal pancreatectomy. In most cancers, the spleen also is removed. In select patients minimally invasive techniques may be used to do this operation. The operation takes three to six hours and typically requires four to six days in the hospital.
Under special circumstances, we may perform total pancreatectomies for certain tumors. For some patients, we may perform smaller resections when appropriate.
