Oncology
Pancreatic Cancer
The pancreas is a gland behind your stomach and in front of your spine. It produces juices that help break down food and hormones that help control blood sugar levels.
The most common type of pancreatic cancer arises from the exocrine glands and is called adenocarcinoma of the pancreas. The endocrine glands of the pancreas can give rise to a completely different type of cancer, referred to as pancreatic neuroendocrine carcinoma or islet cell tumor.
Pancreatic adenocarcinoma is among the most aggressive of all cancers. By the time that pancreatic cancer is diagnosed, most people already have disease that has spread to distant sites in the body.
Risk Factors: * Smoking * Long-term diabetes * Chronic pancreatitis * Certain hereditary disorders * Being male * Over 60 * African American, * Eating a diet high in red meat and low in fruits and vegetables, * Being obese.
Pancreatic Cancer Symptoms * Pain in the abdomen, the back, or both * * Weight loss, often associated with the following: * Loss of appetite (anorexia) * Bloating * Diarrhea or fatty bowel movements that float in water (steatorrhea) * Rarely may present with new diabetes in a person with weight loss and nausea

* Jaundice (yellowing of the skin)
The symptoms of pancreatic cancer are generally vague and can easily be attributed to other less serious and more common conditions. This lack of specific symptoms explains the high number of people who have a more advanced stage of disease when pancreatic cancer is discovered.

Diagnostic Procedure: * Abdominal ultrasound * Abdominal computed tomography (CT): * Percutaneous biopsy * Endoscopic biopsy * Blood test called CA 19-9
Medical Treatment * Chemotherapy and radiation therapy given simultaneously * Chemotherapy alone
Medications
* Gemcitabine (Gemzar) * Fluorouracil (5-FU) * Capecitabine (Xeloda) * Pancrelipase (pancreatic enzyme replacement) may be given if the function of the pancreas is impaired, usually after the surgical removal of a portion of the pancreas.
Surgery:
* Whipple procedure-This is done when the pancreatic cancer is in the head or uncinate process. This procedure removes the head and uncinate process of the pancreas, the duodenum, and the gallbladder. A portion of the stomach is often removed as well. * Distal subtotal pancreatectomy: This is performed when the pancreatic cancer is in the body or tail of the pancreas. This procedure removes the body and tail of the pancreas as well as the spleen.
Other Treatment * Biliary stenting: This involves placing a hollow tube, called a stent, into the bile duct to keep it open despite the external pressure from a growing pancreatic tumor. * Celiac plexus neurolysis (CPN): Sometimes referred to as a celiac block, celiac plexus neurolysis involves an injection of a chemical (usually alcohol) into the collection of nerves called the celiac plexus that receives pain signals from the pancreas. * Radiation therapy is treatment that uses high-energy x-rays aimed at the cancer to kill cancer cells or to keep them from growing. For pancreatic cancer cases, radiation therapy is usually given in conjunction with chemotherapy.

Prevention:
Risk factors that can be controlled include limiting smoking and excessive alcohol intake.

Prognosis:
Pancreatic cancer is a difficult disease. Even for surgically resectable (and therefore curable) tumors, the risk of cancer recurrence and subsequent death remains high. Only about 20% of patients undergoing a Whipple procedure for curable pancreatic cancer live five years, with the rest surviving on average less than two years. For patients with incurable (locally advanced unresectable or metastatic) pancreatic cancer, survival is even shorter; typically it is measured in months. With metastatic disease (stage IV), the average survival is just over six months. Doctors around the world continue to study this terrible disease and strive to improve treatments, but progress has been difficult to come by.

Gallbladder cancer
Cancers of the biliary tract include cholangiocarcinomas (cancers arising from the bile duct epithelium) and gallbladder cancers. Both types of biliary tract cancers are rare and have an overall poor prognosis. They also both present difficulties in diagnosis. These diseases are often discussed together and are co-mingled in therapeutic trials. However, this leads to significant confusion
Risk factor * Gallstones * Porcelain gallbladder * Female gender * Obesity * Older age * Ethnicity and geography * Choledochal cysts * Abnormalities of the bile ducts * Gallbladder polyps * Industrial and environmental chemicals * Typhoid * Family history

Signs and symptoms * Jaundice * Palpable mass in the right upper quadrant (Courvoisier sign, if this is due to a palpable gallbladder) * Periumbilical lymphadenopathy (Sister Mary Joseph nodes) * Left supraclavicular adenopathy (Virchow node) * Pelvic seeding: Mass is palpated on digital rectal examination (Blumer shelf)
TREATMENT
Medical Care: Although complete surgical resection is the only therapy to afford a chance of cure, en bloc resections of the gallbladder and portal lymph nodes carry a high morbidity and mortality (similar to bile duct carcinoma). Adequate surgical margins may be difficult to achieve. The role of adjuvant radiation therapy is to control microscopic residual deposits of carcinoma in the tumor bed and regional lymph nodes. The rationale for radiation therapy with or without concurrent chemotherapy in patients with unresectable disease is to provide palliation of symptoms. Rarely it may also increase survival. * The role of radiotherapy for carcinoma of the gallbladder is unclear because the available literature is derived from small, single institutional experiences over many years, with a variety of treatment methods used. Complicating this is the fact that only approximately 25% of patients with carcinoma of the gallbladder can undergo curative surgery. * Even large institutions do not accrue more than single-digit numbers of patients per year, and many are not on protocol. Available reports contain small numbers of patients with incomplete reporting of technical treatment data, histological grading, and tumor extent. The literature is strongly biased by patient selection, and interpretation of the reports is difficult. Given these difficulties, the data support the following statements: * Radiotherapy has been delivered in a variety of situations, including after curative resections with close or positive microscopic margins, gross macroscopic residual disease, and palliative debulking with bypass. * All patients with tumors beyond the mucosa are candidates for external beam radiotherapy. Patients with curative resection and AJCC stages T2-T4 who have had complete resection who receive radiation have a mean survival of over sixteen months. This is compared to less than 6 months mean survival with surgery alone. * 5-FU–based chemotherapy is usually given in conjunction with concurrent radiation therapy both in the adjuvant and palliative setting. Other chemotherapy drugs have been tested in unresectable gallbladder cancer with no consistent or significant improvement in the known poor prognosis. These drugs include Adriamycin, mitomycin C, and cis-platinum. Patients with a good performance status should be considered for a clinical trial. Patients with a poor performance status may be best treated with supportive care.
Surgical Care: Complete surgical resection is the only therapy to offer a chance of cure in this disease. Unfortunately, only a minority of patients present with early-stage disease and are, therefore, considered for curative resection. * Because of the high incidence of gallbladder cancer in a calcified (porcelain) gallbladder, patients with this finding should be strongly considered for an open cholecystectomy even if they are asymptomatic. It is best to avoid a laparoscopic cholecystectomy in this setting to avoid the risk of peritoneal seeding if, indeed, gallbladder cancer is present. * Patients who present with a gallbladder mass or jaundice are evaluated preoperatively for resectability as previously described. If the tumor is resectable, the patient undergoes a cholecystectomy with en bloc liver resection and regional lymphadenectomy. Bile duct excision may also be necessary (especially if jaundice is present). The operative morbidity and mortality rate increases with the complexity of the operative procedure. * The surgical role in treatment of unresectable disease is usually limited to biopsy of the tumor for diagnosis and possible biliary decompression procedures.
Consultations: A radiation oncologist and medical oncologist should be part of the multidisciplinary team participating in the treatment of patients with gallbladder cancer.
MEDICATION
Historically, chemotherapy has not shown significant activity in gallbladder carcinoma. Typically, 5-flurouracil (5-FU) has been used with response rates of 10-24% in advanced disease. Often 5-FU is administered either as a bolus or as a prolonged infusion regimen with radiation. Capecitabine is a currently available oral alternative to a prolonged 5-FU infusion.
More recently, gemcitabine has shown activity in gallbladder cancer. Early phase studies show an increased response rate with gemcitabine combination therapy over historical treatment response rates with 5-FU alone. Gemcitabine has been studied in combination with cis-platinum and capecitabine.
Currently, no clearly defined standard exists for chemotherapy in gallbladder cancer. Patients should be encouraged to participate in clinical trials.
Deterrence/Prevention:
* Because a calcified (porcelain) gallbladder has up to a 25% incidence of associated gallbladder cancer, this is an indication for a cholecystectomy even in an asymptomatic patient. * A small percentage (less than 10%) of patients with gallbladder polyps are found to have underlying gallbladder cancer. The risk increases with age and the size of the polyp. A cholecystectomy should be considered if a gallbladder polyp greater than 1 cm in size is found in a patient older than 50 years.
Prognosis:
* Survival at 5 years is correlated with stage of disease at presentation. Only 10-20% of patients present with localized disease. The remainder present with regional or distant spread. According to the SEER registry on gallbladder cancer, the 5-year survival rates for localized, regional, and distant disease are approximately 40%, 15%, and less than 10%, respectively. The median survival for advanced disease is short (2-4 mo).
Stages of Gallbladder Cancer
Tests and procedures to stage gallbladder cancer are usually done at the same time as diagnosis.
See the General Information section for a description of tests and procedures used to detect, diagnose, and stage gallbladder cancer.
The following stages are used for gallbladder cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the innermost (mucosal) layer of the gallbladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Stage I
In stage I, cancer has formed. Stage I is divided into stage IA and stage IB. * Stage IA: Cancer has spread beyond the innermost (mucosal) layer to the connective tissue or to the muscle (muscularis) layer. * Stage IB: Cancer has spread beyond the muscle layer to the connective tissue around the muscle.
Stage II
Stage II is divided into stage IIA and stage IIB. * Stage IIA: Cancer has spread beyond the visceral peritoneum (tissue that covers the gallbladder) and/or to the liver and/or one nearby organ (such as the stomach, small intestine, colon, pancreas, or bile ducts outside the liver). * Stage IIB: Cancer has spread: * beyond the innermost layer to the connective tissue and to nearby lymph nodes; or * to the muscle layer and nearby lymph nodes; or * beyond the muscle layer to the connective tissue around the muscle and to nearby lymph nodes; or * through the visceral peritoneum (tissue that covers the gallbladder) and/or to the liver and/or to one nearby organ (such as the stomach, small intestine, colon, pancreas, or bile ducts outside the liver), and to nearby lymph nodes.
Stage III
In stage III, cancer has spread to a main blood vessel in the liver or to nearby organs and may have spread to nearby lymph nodes.
Stage IV
In stage IV, cancer has spread to nearby lymph nodes and/or to organs far away from the gallbladder.
For gallbladder cancer, stages are also grouped according to how the cancer may be treated. There are two treatment groups:
Localized (Stage I)
Cancer is found in the wall of the gallbladder and can be completely removed by surgery.
Unresectable (Stage II, Stage III, and Stage IV)
Cancer has spread through the wall of the gallbladder to surrounding tissues or organs or throughout the abdominal cavity. Except in patients whose cancer has spread only to lymph nodes, the cancer is unresectable (cannot be completely removed by surgery).
Recurrent Gallbladder Cancer
Recurrent gallbladder cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the gallbladder or in other parts of the body.