Pancreatic cancer is one of the common malignant tumors of the digestive tract and is the most common of the malignant tumors, mostly occurring in the head of the pancreas. Abdominal pain and painless jaundice are the common symptoms of pancreatic head cancer. Diabetic patients who smoke a lot for a long time and have a high fat and high animal protein diet have a relatively higher incidence. The disease occurs mostly in middle-aged and elderly people, and there are far more male patients than premenopausal women, and the incidence of postmenopausal women is similar to that of men. The cause of the disease is still unknown, but some environmental factors have been found to be associated with the development of pancreatic cancer. The primary risk factors identified are smoking, diabetes gallstone disease, alcohol consumption (including beer) and chronic pancreatitis, and eating a high-fat, high-protein diet and refined flour foods.
I. Introduction of pancreatic cancer
Cancer of pancreas, pancreatic cancer was first described by Mondiare and Battersdy. 1888, Bard and Pis made a clinical report in the literature. 1935, Whipple, a famous American surgeon, first reported the success of pancreatic and duodenal resection, thus establishing the way of surgical treatment of malignant tumors of pancreas, duodenum and jugular abdomen. In 1943, Rockeg firstly performed total pancreatectomy. Yu Man-kwong in China first reported a case of pancreatic head duodenectomy in 1954. In recent years, the incidence of pancreatic cancer has been increasing year by year, in the United States in 1988 the incidence rate was 9.0/100,000, male: female 1.3:1. Mostly seen in people over 45 years of age. The incidence rate in Sweden is higher, 125/100,000, and has remained constant over the past 20 years. The standardized incidence rates in Canada, Denmark and Poland increased by more than 50% in the 70s compared to the 60s. In China, pancreatic cancer has become one of the top 10 malignant tumors that kill our population. The Peking Union Medical College Hospital in Beijing in recent years admitted pancreatic cancer patients than in the 1950s increased by 5-6 times. And according to the analysis of 354 cases in 7 hospitals in Beijing, 80% of the patients are aged 41-70 years old, and in recent years, the trend of young pancreatic cancer patients has increased significantly compared to 10 years ago, and the malignancy is higher and the prognosis is worse. As far as the site of pancreatic cancer is concerned, the head of the pancreas is the most common, accounting for about 70% of the cases, followed by the body of the pancreas and the tail of the pancreas, some of which have both head, body and tail, and are diffuse or multicentric lesions.
The main causes of pancreatic cancer
Due to the improvement of people’s living standard, the change of people’s diet and living habits has caused the accelerated acidification of human body, acidic physique has caused the slowing down of human metabolic cycle, weakening of normal cell activity, cellular hypoxia, causing organ lesions and endocrine imbalance, resulting in chronic diseases such as pancreatitis or pancreatic duct hyperplasia.
Acidification of body fluids causes a decrease in the amount of dissolved oxygen in the cells, and when it drops to 65% of the normal value, it leads to the death of cells, and there are cells that do not hesitate to change their chromosomes to survive, which becomes cancer cells.
Occupation related to pancreatic cancer is the work with chemicals and metal contact, chemotherapy contamination will cause mutation of cells, and mutated cells will grow like crazy in acidic body fluids, which is another big reason to get pancreatic cancer.
Staging and staging of pancreatic cancer
(i) Western medical pancreatic cancer staging
Western medical staging refers to the international TNM staging and clinical staging of pancreatic cancer.
1. International TNM staging of pancreatic cancer (UICC, 1987), T refers to primary tumor, N refers to lymphatic metastasis, and M refers to distant metastasis.
(1) Primary tumor (T) staging.
Tx: cannot be judged.
T0: No evidence of primary tumor.
T1: primary tumor did not go beyond the pancreas.
T1a: tumor ≤2cm.
T1b: tumor >2cm.
T2: Tumor invaded duodenum, bile duct or peri-pancreatic tissues.
T3: Tumor invades stomach, spleen, colon and large blood vessels.
(2) Small regional lymph node (N) staging
N x: Cannot be judged.
N 0: no metastasis in regional lymph nodes.
N 1: There is regional lymph node metastasis.
(3) Distant metastasis (M) staging.
Mx: Cannot be judged.
M0: No distant metastasis.
M1: with distant metastasis.
2.Clinical staging
Stage I: T1 N0 M0; T1 NX M0; TX N0 M0; TX NX M0.
Stage II: T2 N0 M0; T2 NⅩ M0; T3 N0 M0; T3 NⅩ M0.
Stage III: any T, N1, M0:.
Stage IV: any T, any N, M1.
The clinical staging of pancreatic cancer is of great importance for the choice of surgery and the advantages and disadvantages of treatment methods. The Japanese Pancreatic Society divided it into four stages: ① Stage I: tumor diameter less than 2 cm, no regional lymph node metastasis, no infiltration of the pancreatic pericardium, retroperitoneum, portal vein, superior mesenteric vein and splenic vein; ② Stage II: tumor diameter 2.1-4.0 cm, metastasis in the lymph nodes immediately adjacent to the tumor, possible metastasis in the pancreatic pericardium, retroperitoneum and the aforementioned vessels; ③ Stage III: tumor diameter 4.1-6 cm, station 1 There is metastasis in the lymph nodes between station 1 and station 3, and there is infiltration in the pancreatic peritoneum and retroperitoneum; ④ Stage IV: tumor diameter is greater than 6.1 cm, metastasis in the lymph nodes of station 3, invasion of adjacent internal organs, extensive infiltration in the retroperitoneum and the aforementioned veins.
(ii) Pathological classification of pancreatic cancer in Western medicine
1.Ductal adenocarcinoma
Ductal adenocarcinoma accounts for 80%-90% of pancreatic adenocarcinoma and is mainly composed of glands with duct-like structures of different degrees of differentiation, accompanied by abundant fibrous interstitium. Highly differentiated ductal adenocarcinoma mainly consists of well differentiated duct-like structures lined with highly columnar epithelial cells, some of which are mucinous-like epithelium and some of which have abundant eosinophilic cytoplasm. This carcinomatous duct is sometimes difficult to distinguish from residual and hyperplastic ducts in the setting of chronic pancreatitis. The moderately differentiated ones consist of duct-like structures with different degrees of differentiation, some of which are similar to highly differentiated adenocarcinomas, and some of which may have realistic cancer nests. The low-differentiated ones only have a few irregular glandular lumen-like structures, and most of them are solid cancer nests with great cellular anisotropy, ranging from undifferentiated small cells to tumor giant cells or even multinucleated tumor giant cells, and sometimes spindle cells can be seen; in the few areas with glandular lumen-like differentiation, there can be a small amount of mucus, and the interstitium of the tumor is rich in type I and IV collagen.
2.Special types of carcinoma of ductal origin
Polymorphic carcinoma: also called giant cell carcinoma, it may be a subtype of ductal carcinoma. It is composed of oddly shaped mononuclear or multinucleated tumor giant cells, or even spindle-shaped cells, which may sometimes resemble osteoblastic giant cells or choriocarcinoma-like cells. The tumor cells are arranged in solid nests or in a sarcoma-like arrangement.
Adenosquamous carcinoma: Occasionally seen in the pancreas, it may be the result of squamous malignant transformation of pancreatic duct epithelium. The tumor consists of adenocarcinoma and squamous carcinoma components. Pure squamous carcinoma is quite rare in the pancreas.
(3) Mucinous carcinoma: The cut surface can be jelly-like, very similar to the colonic colloid carcinoma. Under light microscopy, the tumor contains a large amount of mucus, forming a mucus pool. Cells may be suspended in it or scattered at the edge of the mucus pool.
Mucinous epidermoid-like carcinoma and indolent cell carcinoma: Occasionally seen in the pancreas.
(5) Ciliated cell carcinoma: The morphology is the same as that of general ductal carcinoma, characterized by some cells with cilia.
3.Alveolar cell carcinoma
The tumor cells are polygonal, round or short columnar in shape. The nucleus is round and often located at the base. The tumor cells are arranged in vesicular or lacunar shape, and the cytoplasm is strongly eosinophilic and granular. Both electron microscopy and immunohistochemistry show the characteristic features of adenosarcoma cells, such as abundant rough endoplasmic reticulum and zymogen granules. Follicular cell carcinoma mainly metastasizes to local lymph nodes, liver, lung or spleen.
4.Small glandular carcinoma
It is a rare type of pancreatic cancer. It is more common in the head of pancreas. Microscopically, the tumor consists of many small glandular structures and solid nests with slender fibrous septa between them. The cells may be cuboidal or columnar in shape, with relatively uniform nuclei. Recent studies suggest that this type of pancreatic cancer may be a compound tumor of alveolar cells and endocrine cells.
5.Large eosinophilic granular cell carcinoma
This type of tumor is rare. The tumor cells have abundant eosinophilic granular cytoplasm with round or ovoid nuclei and are arranged in small nests. There are fibrous septa separating them. The cytoplasm of electron microscopic tumor cells is filled with hypertrophic mitochondria.
6.Small cell carcinoma
Small cell carcinoma of the pancreas is morphologically similar to small cell carcinoma of the lung and accounts for about 1% to 3% of pancreatic adenocarcinoma. It is composed of consistent small round cells or oat-like cells with little cytoplasm and many nuclear divisions, often with hemorrhagic necrosis and positive NSE immunohistochemical staining. Most die within 2 months. Its origin is still unclear.
4. Diagnosis of pancreatic cancer
Some researchers believe that pancreatic cancer should be suspected in patients aged 40 years or older who have any of the following clinical manifestations: (1) obstructive jaundice; (2) recent unexplained weight loss of more than 10%; (3) recent unexplained pain in the upper abdomen or lower back; (4) recent indistinct and unexplained dyspepsia with a normal gastrointestinal tract on barium meal; (5) sudden onset of diabetes mellitus with no factors contributing to its onset, such as family history, or (6) a history of diabetes mellitus. (6) sudden onset of unexplained steatorrhea; (7) spontaneous onset of pancreatitis. The suspicion should be doubled if the patient is a smoker.
(1) The initial diagnostic test of choice is a CT scan. This scanner is not dependent on surgery, is not limited by the patient’s size or gastrointestinal gas, and can identify liver metastases, lymphatic lesions, and peripheral vascular invasion, but is unreliable in diagnosing damage smaller than 2 cm or small peritoneal nodules.CT can determine the stage of disease the patient is in and provide information in cases where surgery cannot be performed. If distant metastases, invasion of adjacent organs, encapsulation or invasion of blood vessels, and lymphatic lesions are found, the tumor cannot be surgically removed. However, CT is not precise enough for the diagnosis of resectable tumors. Percutaneous fine-needle aspiration biopsy can be performed under CT guidance because of the need to determine the histological diagnosis, which is especially important for inoperable patients.
(2) Ultrasonography is less expensive than CT, easily available, and can see liver, intrahepatic and extrahepatic bile duct tumors with sensitivity and specificity of more than 90%. The accuracy of ultrasound diagnosis is limited by the operator’s technique, the patient’s hypertrophy and gastrointestinal gas. Usually, ultrasonography is used as a complementary test to CT.
(3) Magnetic resonance imaging (MRI) is not more useful than CT in confirming pancreatic cancer, and it cannot show advantages over CT, but being a specialized technique in this field, it may play a role in the future from a developmental point of view.
(4) Retrograde cholangiopancreatography (ERCP) is particularly useful in identifying bile duct stones, in making a diagnosis of bile duct damage and in obtaining tissue biopsies of duodenal and jugular cancers. If compression or blockage is found – known as duplexism – small pancreatic head damage can be diagnosed. The image of the pancreas is rarely normal in the presence of pancreatic malignancy, and unresectable pancreatic cancer usually has bile duct dilatation. ERCP provides a basis for the possibility of duodenal papillotomy and localizes the endoprosthesis so that surgical decompression can be avoided. The insertion of endoscopy with the help of ultrasound provides a new method for diagnosing pancreatic tumors, and this technique offers the possibility of early diagnosis.
(5) Fine-needle aspiration (FNA) cytology under CT or ultrasound guidance has an accuracy of 76% to 90% for the diagnosis of pancreatic cancer, with a specificity of almost 100%. FNA may be particularly useful when there is no indication for surgery or when surgery is not desired, whether for pancreatic tail, pancreatic body damage or metastatic lesions.
V. Clinical manifestation symptoms of pancreatic cancer
Initial symptoms.
Gastrointestinal disturbances (loss of appetite, etc.).
Persistent dull pain in the upper abdomen unrelated to diet.
If you do not like fatty dishes, you may have fatty diarrhea, which is a symptom of diarrhea in which fat is not digested and mixed with feces and excreted.
Abdominal pain is an early symptom of pancreatic cancer, mostly seen in pancreatic body and tail cancer, located in the upper abdomen, around the umbilicus or right upper abdomen, with the nature of colic, paroxysmal or continuous, progressively aggravated dull pain, mostly radiating to the lumbar back, aggravated in the lying position and at night, and can be relieved when sitting, standing, leaning forward or walking.
Jaundice can be present at a certain stage of the disease process, generally jaundice is more common in pancreatic head cancer and appears earlier, but there is no jaundice when the cancer is limited to the body and tail. Jaundice is mostly obstructive, progressive and deepening, accompanied by itchy skin and other symptoms.
About 90% of patients have rapid and significant weight loss, which is often accompanied by cachexia in the advanced stage of pancreatic cancer.
Weakness and loss of appetite are very common, and may be accompanied by gastrointestinal symptoms such as diarrhea and constipation, abdominal distention and nausea. In some cases, steatorrhea, hyperglycemia and diabetes may appear.
5. Fever may occur due to secondary bile duct infection as a result of cancer ulceration or infection.
6.Some of the pancreatic body and tail cancer can be seen as thrombophlebitis in the limb vein, causing local limb swelling.
In addition to jaundice, physical examination may reveal epigastric pain. In advanced stage, nodular and hard masses may be palpated in the upper abdomen. If jaundice is accompanied by enlargement of the gallbladder, it is an important basis for pancreatic head cancer. Due to bile accumulation, enlargement of the liver can often be detected. If the cancer compresses the splenic vein or splenic vein thrombosis, splenomegaly can be detected.
In advanced pancreatic cancer, ascites may appear, and hard and enlarged metastatic lymph nodes may be found in the left supraclavicular or anterior rectal recess.
How to prevent pancreatic cancer
1. Develop good habits, quit smoking and limit alcohol. Smoking, the World Health Organization predicts that if people stop smoking, after 5 years, cancer in the world will be reduced by 1/3; secondly, do not abuse alcohol. Cigarettes and alcohol are extremely acidic acids, and long-term smoking and drinking are very likely to lead to an acidic body.
2.Don’t eat too much salty and spicy food, don’t eat overly hot, cold, expired and spoiled food; eat cancer prevention food and alkaline food with high alkaline content as appropriate for those who are old and weak or have certain disease genes, and keep a good mental state.
3. Have a good state of mind to cope with stress, combine work and rest, and do not overwork. It can be seen that stress is an important cause of cancer. According to Chinese medicine, stress leads to overwork and physical deficiency, thus causing a decrease in immune function, endocrine disorders and metabolic disorders in the body, resulting in the deposition of acid in the body; stress can also lead to mental tension causing qi stagnation and blood stagnation and internal trapping of poisonous fire, etc.
4, strengthen physical exercise, enhance physical fitness, more exercise in the sun, more sweating can be acidic substances in the body with.