I am called by a colleague from the A&E to see a patient who had been admittd for jaundice. This morning after waking up, when stepping into the bathroom – in front of the mirror – to shave, this 55-year-old man noticed in his reflection that his skin was a light shade of yellow. To a specific question, he replies that for a few days his urine had been particularly dark and his stools a grayish-white colour. I ask if he is in pain and he replies that he has not had any but at times he feels a little swollen and he happens to have vomiting fit, especially after eating, but this does not always happen, especially in the last six or seven days. At home, he takes one tablet a day for hypertension and a few weeks ago he started taking metformin for a recently diagnosed diabetes. He hasn’t lost weight, but his appetite is no longer what it used to be. In fact, his skin is deeply jaundiced, and his blood tests are impaired. A CT scan that the A&E colleague has already requested shows dilation of the biliary tract, which means the tubes that carry bile from the liver to the intestine, but in this case they are blocked by a 3 cm mass of the head of the pancreas that infiltrates and occludes the common bile duct, which is the main one of these tubes. The pancreatic duct is also dilated and the mass appears to infiltrate the portal vein, which is the main vessel that carries blood to the liver. Clearly, it is not an easy condition, but all in all there should be room for a multidisciplinary treatment. I explain to the patient that there is a mass of the pancreas and that it would seem quite large, but I warn him that we will have to perform other diagnostic procedures to get a complete picture. At the mention of the pancreas, the patient seems very worried. I call his wife to stand beside him while I explain to him what will happen in the coming weeks. They will find themselves fighting perhaps the greatest war they have fought in their life, and they will have to strengthen and support each other. The fight against cancer cannot be fought alone …
Pancreatic cancer is one of the most aggressive and malignant neoplasms of the digestive system. It often presents itself subtly, and this explains the frequent delay in diagnosis. Sometimes, when jaundice sets in, it is already too late. Jaundice occurs only when the mass affects the head of the pancreas (i.e., the rightmost part, near the liver and biliary tract). Fortunately, in this case the mass appears to be limited to the pancreas, even if it is in close contact with the portal vein, but it still seems to be removable with a surgical operation. The information we get from the CT scan is not enough to have the complete picture and to be able to plan the operation, and it is necessary to perform other diagnostic tests to be sure that the tumour is curable. An MRI scan of the pancreas and above all an endoscopic ultrasound (i.e., an ultrasound examination performed from inside the stomach with an ultrasound probe mounted over an endoscope) are essential. Confirmation with a biopsy of the lesion may not be necessary, as the mass must be removed anyway, if possible. We must make sure that the mass does not extend excessively beyond the pancreas, which would make the operation potentially futile and dangerous. In case of advanced cancer, it is possible to consider neoadjuvant chemotherapy (i.e., to be performed before surgery) in order to reduce the mass, if possible, and its extensions beyond the pancreas. In some cases, unfortunately, nothing can be done …
At the Unit of Digestive and Emergency Surgery of the Terni Hospital, open and minimally invasive surgery (with the DaVinci XI surgical robot) are used for the radical treatment of these tumours, but we have also implemented innovative therapies such as stereotaxic radiotherapy and electroporation to be used in inoperable cases to try to improve survival and quality of life. These two methods are considered when the tumour is not surgically removable, and have high success rates reported by scientific studies. With stereotaxic radiotherapy, a high dose of radiation is focused on the malignant mass, with the intention of destroying it without damaging the contiguous structures. Electroporation is a surgical procedure (in open or minimally invasive surgery) to destroy the tumour nodule by applying intense electric fields on a small area. Of course, surgical resection is always the best choice, where possible, even if it involves a long and difficult operation.
Pancreatoduodenectomy is an operation that removes masses of the head of the pancreas as well as of the choledochus (also known as common bile duct) and of the duodenum, often together with a tract of the stomach and lymph nodes that are found around the pancreas and around the main arteries. It is a very complex surgery that is more often performed traditionally, but in our Unit of Digestive and Emergency Surgery, minimally invasive robotic pancreatoduodenectomy is in the routine practice, along with robotic resection of the body and tail of the pancreas, as well as of the stomach, large bowel, liver and other abdominal organs. Cancers of the body and tail of the pancreas are usually treated by removing the part of the pancreas near the mass along with the spleen and regional lymph nodes. This surgery, splenopancreasectomy, is currently performed laparoscopically or robotically, with minimal postoperative pain and quick recovery, while at the same time the complication rate is significantly reduced compared to the traditional technique, due to the refinement of pre, intra and postoperative techniques and protocols. The treatment of pancreatic tumours like this, as well as any other type of tumour, no longer depends on the choice of a single doctor but is only possible thanks to the synergy of different specialists, each of whom has specific expertise in a particular aspect of cancer and gives his or her personal contribution to the benefit of each patient.