Tumors of the pancreas

It is an examination that allows for ahigh-resolution ultrasonography (power of resolution about 1-2 mm) of the walls of the esophagus, stomach, duodenalo. Echoendoscopy also has the ability to investigate, with high accuracy, some organs and districts closely adjacent to the digestive tract such as the pancreas, biliary tract, and mediastinum and to investigate the related vascular and lymph node stations.

The examination is performed with an instrument similar to those used for traditional endoscopy: theecoendoscope, which has endoscopic viewing optics at its end, and a miniaturized ultrasound probe that allows evaluation of the gastrointestinal wall and adjacent organs and/or districts.

EUS is a second-level examination that can provide very detailed information that other, noninvasive diagnostic methods cannot.

Echoendoscopic examination of the upper digestive tract is very similar to gastroscopy but requires a significantly longer lead time, which may vary depending on the indication or the need to perform a therapeutic operative procedure. For these reasons, the examination is performed with anesthesia assistance. In selected cases for particularly complex procedures, general anesthesia with orotracheal intubation may be necessary.

The instrument is introduced through the mouth and conducted under direct endoscopic vision to the duodenum passing through the esophagus and stomach.

For exploration of the upper digestive tract (esophagus, stomach, duodenum, biliary tract, pancreas, and mediastinum), it is necessary to have been fasting for at least 8 hours for solids and 2 hours for liquids

An operative procedure called needle aspiration (EUS-FNA-FNB) can be performed during echendoscopy : it consists of taking a minimal amount of material through dedicated needles that are inserted, under echendoscopic vision, into the organ tissue. The material is then sent for cytologic or histologic evaluation.

ERCP is an invasive endoscopic examination performed at the Division of Gastroenterology and Digestive Endoscopy. It allows the identification and resolution of causes that hinder the outflow of bile and pancreatic juices in the intestines.

The procedure is performed under narcosis, on an inpatient basis. The patient is positioned prone, supine or on the left side, depending on technical requirements. A duodenoscope, a flexible probe equipped with a light and side camera that transmits images to a screen, is introduced through the mouth. The duodenoscope reaches the duodenum, where Vater’s papilla, a small orifice from which the bile and pancreatic ducts flow.

Through an operative channel of the duodenoscope, instruments for diagnostic-therapeutic procedures are inserted. Initially, a cannula is introduced into the papillary orifice to inject a radiopaque contrast agent into the bile and pancreatic ducts. With X-rays, images of the filled ducts can be viewed on a radiology monitor to refine the diagnosis and plan the surgery.

This is followed by the therapeutic phase, which almost always involves a sphincterotomy: a small cut of the papillary orifice to allow access and necessary maneuvers. The procedure takes about 60 minutes and requires fasting for at least 12 hours.

Given theuse of X-rays, all women of childbearing age must be certain that they are not pregnant; if in doubt, a test is performed before the procedure.

During ERCP, the following can also be performed:

• Biopsies: taking small tissue samples for histological analysis

• Biliary or pancreatic sphincterotomy: cutting the muscle that closes the ducts at the level of Vater’s papilla, to operate in the upstream ducts

• Prosthesis (stent) placement: plastic or metal prostheses to recanalize narrowing or stenosis of the bile and pancreatic ducts. In the case of tumor stenosis, stents can be used preoperatively to resolve jaundice or as palliative therapy in inoperable patients

ERCP is a complex procedure with possible complications such as acute pancreatitis (3.5%), hemorrhage (1.3%), perforation (0.1-0.6%), and infection (1-2%).

In order to complete the diagnosis and staging of pancreatic cancer, they can also be performed:

• CT scan of the abdomen and chest with contrast medium

• Cholangio-Magnetic Resonance

Through a blood test, it is possible to measure the amount of two particular proteins, called tumor markers, that may be produced by pancreatic cancer cells: CEA (Carcino-Embryonic Antigen) and CA19-9.

Their concentration in the blood correlates with the extent of the tumor and tends to increase with disease progression. When present, these markers are useful for assessing the severity of the tumor, monitoring its progress over time, and checking the effectiveness of the therapies taken.

The diagnosis of the tumor is obtained by thehistologic examination performed by the anatomo-pathologist on the samples taken during echo-endoscopy or ERCP.

In tumor diagnosis, the pathologist describes the architecture as a whole (histologic type). The definition of histologic type has its own biological significance and is useful information for treatment planning purposes.

The main types of pancreatic cancer are:

• adenocarcinoma: the majority of pancreatic neoplasms belong to this histotype,
• neuroendocrine carcinoma: This is a rarer tumor that requires different treatment than adenocarcinoma,
• cystic tumors (mucinous and serous),
• IPMN (intraductal mucinous papillary neoplasm).

Surgery is proposed when the tumor is still localized to the pancreas: in the case of patients with adenocarcinoma, this percentage is around 25%, higher in other histologic types. Surgical intervention differs depending on the location of the lesion:

• duodenocephalopancreasectomy: is indicated in pancreatic head tumors and involves en bloc removal of the head of the pancreas, duodenum, the last part of the stomach, gallbladder, and biliary tract.
• distal pancreasectomy: in case of lesions of the body or tail, these portions are removed en bloc with the spleen.
• total pancresectomy: is the surgery by which the entire pancreas, a portion of the small intestine, part of the stomach, bile duct, gallbladder, spleen, and most of the regional lymph nodes are removed.

These interventions can be performed open or, in selected cases, with minimally invasive techniques such as laparoscopy or robotics.

In any case, these are complex operations, both in the demolition and reconstructive phases, burdened by a high rate of postoperative complications: for this reason, they must be performed in specialized centers with adequate volume and experience.

If the tumor has spread to distant organs and is judged inoperable, the surgeon may still decide to intervene to relieve symptoms by performing procedures such as biliary bypass or gastric bypass.

In recent years, the ERAS (Enhanced Recovery After Surgery) philosophy has become increasingly popular, which allows the patient a faster recovery from surgical trauma through a whole series of arrangements, including: adequate preoperative counseling with the patient, comprehensive prehabilitation, selective use of bowel preparation and naso-gastric tube, early removal of the bladder catheter, little or no use of intravenous morphine derivatives, the use of drugs that stimulate bowel motility, the use of peridural catheter (which releases analgesic drugs directly at the level of the spinal cord without the constipating effects of morphinics given by the venous route), early resumption of ambulation, and early introduction of fluids and food by mouth.

All these arrangements resulted in a faster resumption of normal physiological and behavioral functions, shortening the hospital stay thus reducing complications, the risk of hospital infections and thromboembolic changes.

Upon discharge, you will be scheduled for a follow-up appointment. At that time, physicians will give the patient the result of the final histologic examination and schedule subsequent oncologic checkups (follow-up).

Chemotherapy consists of the use of particular cytotoxic drugs that aim to inhibit the growth and proliferation of cancer cells To the point of causing his death. Indeed, one of the characteristics of cancer cells is uncontrolled proliferation, which–at the same time–makes them potentially more vulnerable to chemotherapy. However, some cells in our body physiologically proliferate quickly, which is why they can be damaged by chemotherapy, causing the so-called “side effects” that will be discussed later.

Chemotherapy drugs are administered through treatment cycles with varying cadence (daily, weekly, trisweekly), the duration of which depends on the drugs used but usually does not involve hospitalization with overnight stay.

In some cases, although there is a tumor judged by the surgeon to be potentially resectable, chemotherapy or chemo-radiotherapy treatment may need to be given before and/or after surgery, referred to as peri-operative treatment. Not all patients are candidates for such treatment as the indication is dependent on stage and risk factors.

Peri-operative treatment can be of two types:

• adjuvant, or performed after surgery in order to reduce the risk of recurrence due to the possibility that some tumor cells too small to be visualized by the naked eye may have remained;
• neoadjuvant, i.e., before surgery, in order to make surgery less invasive and decrease the risk of local recurrence, particularly in those cases where there is tumor invasion of lymph nodes near the pancreas.

Standard treatment of advanced cancers involves the use of chemotherapy. In these cases, chemotherapy is primarily aimed at chronicizing the tumor disease.

Chemotherapeutic drugs generally used for the treatment of pancreatic cancer are:

• 5-Fluorouracil (5FU) combined with folinic acid (intravenous route)
• Gemcitabine (intravenous route)
• Irinotecan (intravenous route)
• Cisplatin (intravenous route)
• Oxaliplatin (intravenous route)
• Nab-Paclitaxel (intravenous route)
• Capecitabine (oral route)

These drugs can be carried out In combination with each other or used individually or still sequentially in relation to the clinical picture. The oncologist evaluates several factors-the site affected by the tumor, the general condition, and the type of chemotherapy already received-before making the most appropriate treatment proposal.

Finally, numerous clinical trials are underway with the goal of identifying the most effective chemotherapy treatment for advanced cancers and the best way to administer these drugs. Still, molecules with a different mechanism of action than chemotherapeutic drugs, characterized by greater selectivity toward cancer cells and thus fewer side effects, are being tested. Therefore, in some cases, the oncologist might propose participation in taking part in a clinical trial.

Side effects of chemotherapy

Reactions to chemotherapy vary from subject to subject and are usually time-limited in duration. Among the side effects most common we have nausea/vomiting, skin rashes, reductions in red, white and platelet cells, fatigue, hair loss (alopecia).

To date, we have at our disposal numerous principals and drugs that can effectively prevent and treat almost all side effects. However, tolerance to chemotherapy is subjective, and it is not uncommon to adjust the dosages or timing of treatment to suit the patient’s characteristics.

Radiation therapy is a localized therapy, non-invasive that, through the use of high-energy radiation (ionizing radiation), is able to damage and bring to necrosis neoplastic cells localized at the level of the treatment area,

Radiation therapy is commonly performed on an outpatient basis, on a daily basis, excluding Saturdays, Sundays and holidays. The duration of each treatment generally varies between ten to twenty minutes and the number of sessions depends on several factors, both related to radiotherapy techniques and the stage of disease, and generally ranges from one to four to six weeks. Such treatment does not make one radioactive, and allows one to be in contact with other people without danger throughout the period.

Radiation therapy in pancreatic cancers can be used alone or in combination with chemotherapy depending on the presentation and stage of disease.

Radiation therapy may be used with stereotactic technique (a highly complex technique involving the delivery of high doses per fraction with extreme precision in a small number of sessions), which conventional, both preoperatively, postoperatively, and in cases of persistent disease after surgery.

Finally, radiotherapy can be used for antalgic purposes and to reduce disease where it is symptomatic (presence of pain, jaundice or other symptoms from infiltration of abdominal organs).

Among the side effects most common include nausea, gastrointestinal upset and fatigue (or asthenia).

The cancer patient is often a fragile patient, who needs help and support in his or her disease journey: when he or she experiences an ailment, whether related to the disease or a side effect of therapy, he or she should be able to receive a specialist’s opinion quickly, through a “fast track.”

For this reason, at the Candiolo Institute there is an assistance service every day, Monday through Friday from 8 a.m. to 5 p.m.: just call the secretary of the Oncology Day Hospital (011.993.3775 ) reporting the need for an urgent consultation, and the patient is quickly contacted by his or her specialist doctor.

At the Candiolo Institute, specialists from different disciplines are available at Candiolo for patients who need or request them to offer:

• • nutritional support

• • psychological support

• • physiotherapy

• • dressing of venous access devices

• • pain therapy

• • Management of other coexisting conditions.

Social work

The Social Service Department of the Candiolo Institute conducts information and orientation interviews for patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. – Phone: 011.993.30

With the conclusion of the course of treatment, the follow-up period begins during which, through a series of examinations and visits, the side effects of the therapies performed, their effectiveness, and the patient’s functional recovery are monitored.

Follow-up examinations are especially important to intercept any recurrences early so that appropriate therapy can be intervened. For the patient, they are also a valuable opportunity for dialogue with their medical specialist.

It is the same specialist doctor who schedules follow-up visits, in which the patient’s health condition is assessed and the required test reports are viewed.

Checkups are performed at scheduled intervals for the duration of 5-10 years and include examination, blood chemistry tests, CEA marker assay, Ca19.9, and CT chest and abdomen with contrast medium.

They have a shorter cadence at first (three to six months), then gradually thin out over time (once a year). The frequency and type of examinations provided depend on the stage of the tumor and the treatments given.

Due to the high number of cases treated each year, the Candiolo Institute is a national reference for taking pancreatic cancers. Our experience enables us to deal with even the most complex situations, always with a personalized approach built on the clinical and personal profile of each patient.

Establishing the treatment plan always starts with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies that allow accurate assessment of the extent of the disease.

In addition, the Institute offers advanced and sophisticated laboratory investigations, including molecular and genomic analyses, which are critical for identifying biological features of cancer and guiding therapeutic decisions

When indicated, surgery is performed with minimally invasive techniques (laparoscopic or thoracoscopic), which reduce operative trauma, promote faster recovery, and improve postoperative quality of life. Every treatment choice is defined within the GIC, ensuring a consistent and integrated approach.

As an IRCCS, the Candiolo Institute combines clinical practice with a strong vocation for scientific research. Patients can be evaluated forinclusion in active clinical trials, which represent a real chance to access innovative therapies not yet available in standard practice. Collaboration between care and research is a distinctive value that translates into concrete opportunities for the patient.

The Interdisciplinary Care Group takes care of the person at every stage: from diagnosis to treatment to follow-up, with attention to nutritional support, psychological health, and reintegration into daily life. The organization of checkups, visits and treatment is designed to ensure continuity and serenity, always valuing the human dimension of care.