Pancreas Tumors

It is an examination that enables high-resolution ultrasonography (with a spatial resolution of approximately 1–2 mm) of the walls of the esophagus, stomach, and duodenum. Echoendoscopy also allows highly accurate evaluation of organs and structures in close proximity to the gastrointestinal tract, such as the pancreas, biliary tree, and mediastinum, as well as associated vascular structures and lymph node stations.

The procedure is performed using an instrument similar to that used in conventional endoscopy: the echoendoscope, which combines a distal endoscopic camera with a miniaturized ultrasound probe, allowing detailed assessment of the gastrointestinal wall and adjacent organs and/or anatomical regions.

Endoscopic ultrasound (EUS) is a second-level diagnostic procedure that provides highly detailed information that may not be obtainable through other non-invasive imaging modalities.

Echoendoscopic examination of the upper gastrointestinal tract is comparable to gastroscopy but generally requires a longer procedure time, which may vary depending on the clinical indication or the need to perform interventional procedures. For this reason, the examination is usually carried out under sedation with anesthesiological assistance. In selected cases requiring particularly complex interventions, general anesthesia with endotracheal intubation may be necessary.

The echoendoscope is introduced through the mouth and advanced under direct endoscopic visualization through the esophagus and stomach into the duodenum.

For examination of the upper digestive tract (esophagus, stomach, duodenum, biliary tract, pancreas, and mediastinum), patients must fast for at least 8 hours for solid foods and 2 hours for clear liquids.

During echoendoscopy, an operative procedure known as fine-needle aspiration or biopsy (EUS-FNA/FNB) may be performed. This involves obtaining small tissue or cellular samples using dedicated needles, which are advanced under ultrasound guidance into the target tissue. The collected material is then sent for cytological or histological analysis.

ERCP (endoscopic retrograde cholangiopancreatography) is an invasive endoscopic procedure performed in the Division of Gastroenterology and Digestive Endoscopy. It enables the identification and treatment of conditions that obstruct the flow of bile and pancreatic secretions into the intestine.

The procedure is carried out under general anesthesia and in an inpatient setting. The patient is positioned prone, supine, or in the left lateral decubitus position, depending on technical requirements. A duodenoscope—a flexible endoscope equipped with a light source and a side-viewing camera that transmits images to a monitor—is introduced through the mouth and advanced to the duodenum, where the major duodenal papilla (papilla of Vater) is located, through which the bile and pancreatic ducts drain.

Through the operative channel of the duodenoscope, dedicated instruments are introduced for diagnostic and therapeutic purposes. Initially, a cannula is used to access the papillary orifice and inject a radiopaque contrast agent into the bile and pancreatic ducts. X-ray imaging is then used to visualize the opacified ducts, refine the diagnosis, and guide therapeutic planning.

This is followed by the therapeutic phase, which most commonly includes sphincterotomy: a small incision of the papillary orifice to allow access to the biliary and/or pancreatic ducts and facilitate subsequent interventions. The procedure lasts approximately 60 minutes and requires fasting for at least 12 hours beforehand.

Given the use of ionizing radiation, all women of childbearing potential must confirm that they are not pregnant; if there is any uncertainty, a pregnancy test is performed prior to the procedure.

During ERCP, the following additional procedures may be performed:

• Biopsy: collection of small tissue samples for histological analysis
• Biliary or pancreatic sphincterotomy: incision of the sphincter muscle at the level of the papilla of Vater to access the upstream ducts
• Stent placement: insertion of plastic or metal prostheses to relieve strictures or obstructions of the bile or pancreatic ducts. In malignant stenosis, stents may be used preoperatively to resolve jaundice or as palliative treatment in non-resectable cases

ERCP is a complex procedure associated with potential complications, including acute pancreatitis (approximately 3.5%), bleeding (1.3%), perforation (0.1–0.6%), and infection (1–2%).

For the completion of diagnosis and staging of pancreatic cancer, the following imaging studies may also be performed:

• Contrast-enhanced CT scan of the abdomen and chest
• Magnetic resonance cholangiopancreatography (MRCP)

Through a blood test, it is possible to measure the levels of two proteins known as tumor markers, which may be produced by pancreatic cancer cells: CEA (carcinoembryonic antigen) and CA19-9.

Their concentrations in the blood may correlate with tumor burden and often increase as the disease progresses. When elevated, these markers can be useful in assessing disease extent, monitoring clinical evolution over time, and evaluating response to treatment.

The diagnosis of pancreatic cancer is confirmed through histological examination performed by the pathologist on tissue samples obtained during endoscopic ultrasound (EUS) or ERCP.

In tumor assessment, the pathologist evaluates the overall tissue architecture and determines the histological type. This classification has important biological significance and provides essential information for treatment planning.

The main types of pancreatic tumors include:

• Adenocarcinoma: the most common histological type of pancreatic cancer, accounting for the majority of cases.
• Neuroendocrine tumors/carcinomas: a rarer group of neoplasms with distinct biological behavior and treatment strategies compared to adenocarcinoma.
• Cystic tumors: including mucinous and serous cystic neoplasms.
• IPMN (intraductal papillary mucinous neoplasm): a precursor lesion characterized by intraductal growth and mucin production, with variable malignant potential.

Surgery is proposed when the tumor is still localized to the pancreas. In patients with adenocarcinoma, this condition is present in approximately 25% of cases, while it is more frequent in other histological subtypes. The type of surgical intervention depends on the location of the lesion:

• Pancreaticoduodenectomy (Whipple procedure): indicated for tumors of the pancreatic head. It involves en bloc resection of the pancreatic head, duodenum, distal stomach, gallbladder, and extrahepatic bile ducts.
• Distal pancreatectomy: indicated for tumors of the body or tail of the pancreas, which are removed en bloc, often together with the spleen.
• Total pancreatectomy: involves removal of the entire pancreas, along with a portion of the small intestine, part of the stomach, the bile duct, gallbladder, spleen, and regional lymph nodes.

These procedures may be performed via open surgery or, in selected cases, using minimally invasive techniques such as laparoscopy or robotic surgery.

In all cases, these are highly complex operations, both in the resection and reconstructive phases, and are associated with a significant risk of postoperative complications. For this reason, they should be performed in specialized centers with adequate case volume and expertise.

When the disease has spread to distant organs and is deemed unresectable, surgical intervention may still be indicated for palliative purposes, with procedures aimed at relieving symptoms, such as biliary bypass or gastric bypass.

In recent years, the ERAS (Enhanced Recovery After Surgery) approach has become increasingly established. This multimodal perioperative care pathway aims to promote a faster and safer recovery after surgical procedures by reducing surgical stress and supporting the patient’s functional recovery. It includes a coordinated set of measures such as: thorough preoperative counselling, structured prehabilitation, selective use of bowel preparation and nasogastric tubes, early removal of urinary catheters, minimal or no use of intravenous opioid analgesics, use of prokinetic agents to stimulate bowel motility, and epidural analgesia, which delivers pain control directly at the spinal level while avoiding the systemic side effects of opioids. Additional key elements include early mobilisation and early reintroduction of oral fluids and nutrition.

Collectively, these measures facilitate a more rapid recovery of normal physiological and functional status, shorten hospital stay, and contribute to reducing postoperative complications, including hospital-acquired infections and thromboembolic events.

At discharge, a follow-up appointment is scheduled. During this visit, the final histological results are provided to the patient, and a personalised oncological follow-up plan is defined for subsequent monitoring.

Chemotherapy consists of the use of cytotoxic drugs designed to inhibit the growth and proliferation of cancer cells, ultimately leading to their destruction. A key characteristic of cancer cells is their uncontrolled division, which also makes them particularly susceptible to chemotherapy. However, some healthy tissues in the body also have high rates of cell turnover and may therefore be affected by treatment, leading to the so-called “side effects,” which are described below.
Chemotherapy drugs are administered in treatment cycles with varying schedules (daily, weekly, or every three weeks). The duration and frequency depend on the specific agents used, but treatment is generally delivered on an outpatient basis without the need for hospital admission.
In selected cases, even when a tumor is considered surgically resectable, chemotherapy or chemoradiotherapy may be administered before and/or after surgery as part of a perioperative treatment strategy. Not all patients are eligible for this approach, as indications depend on disease stage and specific risk factors.
Perioperative treatment may be:

• Adjuvant: administered after surgery to reduce the risk of recurrence, addressing possible microscopic residual disease not visible to the naked eye.
• Neoadjuvant: administered before surgery to facilitate resection, potentially reducing tumor size and the risk of local recurrence, particularly in cases involving lymph node involvement near the pancreas.

Standard treatment for advanced disease is based on systemic chemotherapy, which is primarily aimed at controlling tumor progression and transforming the disease into a chronic condition.
Commonly used chemotherapeutic agents in pancreatic cancer include:

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

These drugs may be used in combination, sequentially, or as single agents depending on the clinical scenario. The oncologist selects the most appropriate regimen based on several factors, including tumor location and stage, the patient’s general condition, and prior treatments.
In addition, numerous clinical trials are currently underway aimed at identifying more effective treatment strategies for advanced disease, as well as optimal drug combinations and administration schedules. Novel agents with different mechanisms of action—characterized by greater selectivity for cancer cells and potentially reduced toxicity—are also being investigated. In this context, participation in clinical trials may be proposed by the treating oncologist in selected cases.

Side effects of chemotherapy

Adverse reactions to chemotherapy vary between individuals and are generally temporary. The most common include nausea and vomiting, skin reactions, reductions in red blood cells, white blood cells, and platelets, fatigue, and hair loss (alopecia).

Today, a wide range of supportive therapies is available to prevent and manage most side effects effectively. Nevertheless, tolerance to chemotherapy remains highly individual, and it is not uncommon for treatment doses or schedules to be adjusted based on patient-specific characteristics.

Radiotherapy is a localized, non-invasive treatment that uses high-energy ionizing radiation to damage and induce necrosis in neoplastic cells within the targeted area.

It is typically performed on an outpatient basis, with daily sessions from Monday to Friday, excluding weekends and public holidays. Each treatment session generally lasts between 10 and 20 minutes, while the overall duration of therapy depends on multiple factors, including radiotherapy technique and disease stage, and usually ranges from one to six weeks. Radiotherapy does not make patients radioactive, and they can safely maintain contact with others throughout the treatment period.

In pancreatic cancer, radiotherapy may be used alone or in combination with chemotherapy, depending on disease presentation and stage.

It can be delivered using conventional techniques or highly advanced stereotactic radiotherapy, which allows the administration of high doses per fraction with extreme precision over a limited number of sessions. Radiotherapy may be administered in the neoadjuvant setting, postoperatively, or in cases of residual or persistent disease after surgery.

In addition, it may be used with palliative intent to control symptoms and reduce tumor burden in cases associated with pain, jaundice, or other symptoms due to infiltration of abdominal structures.

The most common side effects include nausea, gastrointestinal disturbances, and fatigue (asthenia).

The cancer patient is often a vulnerable individual who requires support throughout the course of the disease. When new symptoms arise, whether related to the disease itself or to treatment-related side effects, it is essential that the patient can promptly access specialist evaluation through a dedicated “fast track” pathway.

The Candiolo Cancer Institute provides a dedicated assistance service, available Monday to Friday from 8:00 a.m. to 5:00 p.m. Patients may contact the Oncology Day Hospital secretariat at +39 011.993.3775 ) reporting the need for an urgent consultation. The patient is then promptly contacted by their referring specialist physician to ensure timely clinical assessment and appropriate management.

At the Candiolo Cancer Institute, multidisciplinary specialists are available to provide patients, when needed or upon request, with comprehensive supportive care, including:

• Nutritional support
• Psychological support
• Physiotherapy
  Management
• Dressing of venous access devices
• Pain therapy
• Management of coexisting medical conditions

Social work

The Social Service Department of the Candiolo Cancer 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: +39 011.993.30

At the end of the treatment course, the follow-up phase begins. During this period, a series of clinical assessments and diagnostic examinations are performed to monitor treatment-related side effects, evaluate therapeutic efficacy, and assess the patient’s functional recovery.
Follow-up plays a crucial role in the early detection of any disease recurrence, allowing timely intervention with appropriate therapeutic strategies. It also represents an important opportunity for ongoing dialogue between the patient and the treating specialist.
Follow-up visits are scheduled by the same specialist physician, who evaluates the patient’s clinical condition and reviews the results of the required tests.
Surveillance is typically carried out at predefined intervals over a period of 5–10 years and may include clinical examination, blood tests, tumor markers (CEA and CA 19-9), and contrast-enhanced CT scans of the chest and abdomen.
Initially, follow-up is more frequent (every three to six months), and then progressively becomes less frequent over time, eventually transitioning to annual assessments. The frequency and type of investigations are tailored according to tumor stage and the treatments received.

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.