i'm nadim haddad, i'm a member of thedivision of gastroenterology at medstar georgetown university hospital. my area of interest and expertise isinvestigation and management of pancreatic disorders, biliary disorders. most of the patients that come to memainly have problems with the pancreas or the biliary tree and it varies from benign diseasesof the pancreas like pancreatic cysts to malignant disorders of the pancreaslike pancreatic cancer
or bile duct cancer. i occasionally see patients forthe first time when they present with the signs and symptoms suggestive of pancreatic cancer. pancreatic cancer is difficult to diagnose and it requires some very specificand advanced testing, or procedures to be donein order to make a diagnosis and it's important to make the diagnosisas early as possible because that affects the prognosis.in order to diagnose
other benign disordersof the pancreas also, it needs to be down at the center wherea lot of those testings are being done. and some of those procedures and testingsare available in a few places,in a few specialized centers. as an example, endoscopicultrasound is one of them, and this is one of the techniquesthat we have at medstar georgetown. i do enjoy my job, otherwisei wouldn't be here. it's been very fulfilling and challenging,i enjoy taking care of patients,
treating patients, helping patients, and managing their diseases.a lot of times proving that the patient doesn't havepancreatic cancer is very rewarding. i can imagine a patient coming with asuspected diagnosis of pancreatic cancer seen on the test,and they come here, i do the endoscopic ultrasound and determinethat they don't have pancreatic cancer so that's very rewarding to meand very comforting to the patients. the pancreas is a gland in the bodythat serves two major functions, one is to secrete enzymes that wouldhelp with the digestive process,
the second is to secrete the hormonesthat help with the control of sugar and other elements in the body. and the major one is insulin,which helps to control the sugar and if insulin is deficientone might develop diabetes. the other hormones have different functions,like secreting acid in the stomach, and there are a variety of others thatcan cause diarrhea and other conditions. some of the risk factorsinclude smoking, patients that smoke are at slightly higherrisk for developing pancreatic cancer,
family history, patients with family members,first degree siblings, parents, relatives are at high risk for developingpancreatic cancer, patients who are obese,patients who have certain conditions like hereditary pancreatitis,and those are usually young patients that start with recurrent attacksof pancreatitis at an early age, at the age of 20, so those are at high riskfor developing pancreatic cancer throughout their lives, and there are some other congenitalor genetic syndromes that can put the patientsat risk for pancreatic cancers
and the main ones arefamilial adenomatous polyposis, it's a syndrome where patients developthousands of polyps in their colons and those are at high risk.patients with breast cancer are also at a slightly higher risk.unfortunately, the majority of patients who develop pancreatic cancerdon't have an obvious risk factor. pancreatic cancer has beengiven the name of a silent killer because by the time the symptomsor the signs are obvious, it's far advanced to be cured. so one has to have a high index ofsuspicion for pancreatic cancer:
pain, jaundice, wherethe patients turn yellow, weight-loss and loss of appetite,those are the more common ones, and there are others, when it's advanced:change of color, color of urine, color of stools,itching because of the jaundice. the reason is anatomically,the bile duct that drains the liver goes through the pancreas, and...through the head of the pancreas. so if there's a tumor in thehead of the pancreas it causes a mechanical obstructionof the bile duct, so the flow of bile is interruptedand it backs up in the liver,
in the body, the patients turn yellowthey start itching. diagnosis is made mostly by imaging studies and the most common one is a ct scanor what's called "ct scan". a spiral ct scan, which is the mostcommonly used technique nowadays, doesn't take very long and it gives usa very good idea of where the tumor is and whether it has gone or spreadoutside the pancreas and it's important in terms of staging,to know whether the tumor has spread to other organs.as you know, the pancreatic cancer can metastasizeoutside the pancreas to lymph nodes,
to the liver, to the lungs,and this is important information to know because a doctor... that would changea doctor's decision in terms of what treatment to recommend. it's staged using ct scanand also endoscopic ultrasound and i will expand on that. usinglaparoscopy which is a surgical technique, or pet scan is emerging as a new techniquethat has not been proven to play a significant role yet, but itcan help in staging pancreatic cancer. so the ct scan will give us an ideaas i said earlier, if the tumor has spread outsidethe pancreas on out
and to which part of the body. the endoscopic ultrasoundis an endoscopic procedure that would help us determine if the tumoris localized to the pancreas, if it has spread to blood vesselsadjacent to the pancreas with more accuracy. and this is importantbecause that would determine if the tumor can bere-sected or not, surgically. there are 4 main stages,1, 2, 3 and 4. stage 1 refers to the tumorthat is small, that is less than 2cm and is limitedto the pancreas.
stage 2 is broken up into 2:2a and 2b: 2a is a tumor greater than 2cmbut still within the pancreas, stage 2b is greater...is just outside the pancreas. so the tumor has spreadoutside the pancreas and might have some lymph nodes. stage 3 is where the tumor has spreadoutside and spread to lymph nodes. stage 4 is where the tumor has spreadto other organs far from the pancreas. so it's important to knowwhich stages a patient falls into because that has implicationson what type of treatment.
for example, for stage 1 and 2the treatment is surgical and plus or minus chemotherapyand radiation. for stage 3 and 4it depends on each individual and expertise whether to givechemotherapy and radiation to try to shrink the tumor and thentry to re-sect if there's a response. surgery is still... is the cureif the tumor is re-sectable. so that's why we go back to staging, trying to determine if the tumoris small or not. and surgical techniques are varied betweenre-secting the head of the pancreas
or the tail of the pancreas,depending on the location of the tumor. if the tumor is located at the headof the pancreas, the surgery is called a whipple,which most people hear about. it's a major operation but nowadays it's being donelaparoscopically with a minimally invasive technique, and that's something that we areexperienced with here at georgetown, our surgeons have made significantprogress in developing and mastering this technique.
if the tumor is located in the tailof the pancreas then the surgery is calleda distal pancreatectomy. it's a lesser operationand it also can be done laparoscopically, meaning a minimally invasive way.now, this is surgery with the intent to cure, to removethe tumor and cure the patient. there are surgical techniques forpatients who are not curable and those are termedpalliative surgeries. so as i said earlier, the tumorcan block the bile duct and cause jaundice.
the surgeon can bypass the blockageby redirecting the flow of bile from going through the pancreasinto another part of the gi tract. the pancreas can be removed and that's called total pancreatectomy.and the major drawback is that patients lose sugar controlbecause insulin cannot be... is not secreted anymore, but itcan be supplemented by injections like in patients with diabetes.so after total pancreatectomy, a patient will become a diabeticand treated like a diabetic patient. it can, but that's notdone for cancer patients.
transplanting the pancreas is being donefor other indications, for patients with chronic pancreatitis,which is a benign condition, and for other patients. if the tumor is localized, it can besurgically removed. that's the best option the patients have. if the tumor is large and hasspread outside the pancreas, then there are a variety of optionsincluding chemotherapy, radiation, or a combination of the two. now, if the tumor is advanced, meaningit has spread to other parts of the body,
then palliation, that includes endoscopicprocedures, surgical procedures or interventional radiology proceduresto palliate the symptoms of the tumor. endoscopy can be used as a tool to helpwith the diagnosis of pancreatic cancer and to treat pancreatic cancer.in terms of diagnosis, one can use endoscopic ultrasound to get tissue from the pancreasand make the diagnosis, or another procedure called ercp,it's an endoscopy to get inside the pancreatic duct and the bile duct,to get tissue for diagnosis also. endoscopy can be used for palliation.
if the bile duct is blocked by the tumorand the patient is jaundiced, then endoscopy can be used to placea plastic tube called a stent inside the bile duct and bypassthe blockage and relieve the obstruction and improve the patient's jaundice. also one of the techniques that wepioneered at georgetown is endoscopic ultrasound guidedfiducial placement where endoscopies used to placemarkers around the tumor which will help theradiation oncologist to target the cyberknife radiation treatmentfor that tumor.
cyberknife is a concentrated formof radiation that is focused and delivers a high-intensity beamof radiation to the tumor without damaging surrounding tissue.that's a major advantage. and it's used in patients with a tumorthat is locally advanced and it's not clear whether it will bere-sected or removed surgically. so the radiation is used to tryto shrink the tumor and then considerationfor surgical removal. also, cyberknife can be used in patientswho are disease controlled where control the growth of the tumoris required
and this will slow downthe growth of a tumor. we have a pancreatic disease programwhich is a multi-disciplinary... which consists of multi-disciplinarygroups of physicians that get together on a regular basisand come up with the best options to treat patients in different stages,patients mainly with pancreatic cancer. so it's important for patients to seekthis type of concentrated care centers for pancreatic diseases. and also,they would have access to the most up-to-date treatmentoptions and clinical trials because there's a lot of concentratedeffort on
treating patients with pancreatic cancerwith new chemotherapy drugs, new regiments using combinationsof different drugs and radiation. we are using a combinationof different chemotherapy agents before surgery, after surgery,trying to see the effect of the chemotherapy on the tumor,whether it's been able to shrink the tumor. this would have a major implicationon patients' survival, because if you can convert a large tumorinto a smaller tumor and make it surgically removable, you willhave done the patients a great service. molecular testing refers to theexamination of the genetic material
inside the cell of a patient's bodyand it gives us a lot of information about the genetic composition.and in terms of pancreatic cancer, sometimes it's difficult to make thediagnosis by doing a biopsy and so we send the specimen formolecular testing where they look at the geneticcomposition of the tissue or the specimen that's been obtainedand this will help us determine if this is a malignant tumoror a benign tumor or a benign condition. so it plays a significant roleand it would help a lot in terms of pinpointingthe appropriate diagnosis.
the location of the organ, it's locatedin the back of the abdomen what's called the retroperitoneumand it has access to a lot of blood vessels and channelsaround it, so by the time it causes symptomsit would have spread a lot. i think a better diagnosisand earlier diagnosis is essential and i think we're doing that right nowwith a technology being so far-advanced we're able to pick up tumorsas small as 2-3mm of size, and this would have a major impacton prognosis. also, in screening patients who are knownto be at high risk,
this would put the patientin the surveillance program and if they develop changes suggestiveof pancreatic cancer, they can be treated early.also conditions that can progress to pancreatic cancer,we're catching them early and treating, getting a head starton the treatment, and also in terms of chemotherapy,i think our colleagues and oncologists are making significant progressin targeting the inside of the cells and trying to stop the growthof the tumors. it's not clearly known but it'san observation that's been noticed,
it's an association with obesity.most gi cancers are increased in patients who are obese. you know, obesity createsa metabolism... derangement in metabolism and canlead to chronic inflammatory processes inside the body, which can leadto cancer formation. also, you have to ask yourselfwhy are patients obese. is it the diet they're eating? is ita diet that is high in fat? in red meat? and those have been associatedwith pancreatic cancer. medstar georgetown university hospitalhas one of the leading centers in the nation
for pancreatic diseaseand pancreatic cancer specifically. we are a high-volume center,our surgeons are very experienced in treating and managing pancreatic cancers, our colleagues in lombardyhave the most up-to-date chemotherapy regiments to treatpancreatic cancer, our radiology department hasthe most up-to-date technology, technological tests availablebetween ct scans and mris, and the gi endoscopy divisionprovides a wide array of endoscopic techniques and areused for diagnosis and treatment
of pancreatic cancer. so for all...and the service that we provide for our patients in managingtheir disease, in dealing with the disease is veryhelpful and satisfying to the patients.
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