Gastro-intestinal Cancer Surgeon, Ahmedabad, India I Gastro-intestinal cancer surgery, Ahmedabad, India I Gastro-intestinal surgery I Ahmedabad, India

Gastro-Cancer-Surgery : neuro-endo. tumor

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Introduction

Dr Avinash Tank, Gastro-intestinal Cancer Surgeon in Ahmedabad,  Gastro-intestinal cancer surgery in Ahmedabad, Gastro-intestinal surgery in Ahmedabad. Gastro-intestinal Cancer Surgeon in India,  Gastro-intestinal cancer surgery in India, Gastro-intestinal surgery in India.

Pancreatic Endocrine Tumor

The pancreas is a gland about 6 inches long that is shaped like a thin pear lying on its side. The wider end of the pancreas is called the head, the middle section is called the body, and the narrow end is called the tail. The pancreas lies behind the stomach and in front of the spine Anatomy of the pancreas. The pancreas has three areas: head, body, and tail. It is found in the abdomen near the stomach, intestines, and other organs.

There are two kinds of cells in the pancreas:

  1. Endocrine pancreas cells make several kinds of hormones (chemicals that control the actions of certain cells or organs in the body), such as insulin to control blood sugar. They cluster together in many small groups (islets) throughout the pancreas. Endocrine pancreas cells are also called islet cells or islets of Langerhans.
  2. Exocrine pancreas cells make enzymes that are released into the small intestine to help the body digest food. Most of the pancreas is made of ducts with small sacs at the end of the ducts, which are lined with exocrine cells. This summary discusses islet cell tumors of the endocrine pancreas. See the PDQ summary on Pancreatic Cancer Treatment for information on exocrine pancreatic cancer.

A pancreatic neuroendocrine tumor (NET) may also be called a pancreatic endocrine tumor (PET), islet cell tumor, islet cell carcinoma, or pancreatic carcinoid.

Pancreatic NETs are much less common than pancreatic exocrine tumors and have a better prognosis.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

  1. Through tissue. Cancer invades the surrounding normal tissue.
  2. Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, ifbreast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer

Pancreatic NETs may be functional (the hormones that are released cause symptoms) or nonfunctional(the hormones that are released do not cause symptoms) tumors:

  1. Functional tumors make one or more hormones, such as gastrin, insulin, and glucagon, that cause symptoms. Most functional tumors are benign (not cancer).
  2. Nonfunctional tumors make substances that do not cause symptoms. Symptoms are caused by the tumor as it spreads and grows. Most nonfunctional tumors are malignant (cancer).

Most pancreatic NETs are functional tumors.

There are different kinds of functional pancreatic NETs.

Pancreatic NETs make different kinds of hormones such as gastrin, insulin, and glucagon. Functional pancreatic NETs include the following:

Gastrinoma: A tumor that forms in cells that make gastrin. Gastrin is a hormone that causes the stomach to release an acid that helps digest food. Both gastrin and stomach acid are increased by gastrinomas. When increased stomach acid, stomach ulcers, and diarrhea are caused by a tumor that makes gastrin, it is called Zollinger-Ellison syndrome. A gastrinoma usually forms in the head of the pancreas and sometimes forms in the small intestine. Most gastrinomas are malignant (cancer).

Insulinoma: A tumor that forms in cells that make insulin. Insulin is a hormone that controls the amount of glucose (sugar) in the blood. It moves glucose into the cells, where it can be used by the body for energy. Insulinomas are usually slow-growing tumors that rarely spread. An insulinoma forms in the head, body, or tail of the pancreas. Insulinomas are usually benign (not cancer).

Glucagonoma: A tumor that forms in cells that make glucagon. Glucagon is a hormone that increases the amount of glucose in the blood. It causes the liver to break down glycogen. Too much glucagon causes hyperglycemia (high blood sugar). A glucagonoma usually forms in the tail of the pancreas. Most glucagonomas are malignant (cancer).

Other types of tumors: There are other rare types of functional pancreatic NETs that make hormones, including hormones that control the balance of sugar, salt, and water in the body. These tumors include:

  1. VIPomas, which make vasoactive intestinal peptide. VIPoma may also be called Verner-Morrison syndrome.
  2. Somatostatinomas, which make somatostatin.

These other types of tumors are grouped together because they are treated in much the same way.

Having certain syndromes can increase the risk of pancreatic NETs.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk.

Multiple endocrine neoplasia type 1 (MEN1) syndrome is a risk factor for pancreatic NETs.



Symptoms

Different types of pancreatic NETs have different signs and symptoms. Symptoms can be caused by the growth of the tumor and/or by hormones the tumor makes. Some tumors may not cause symptoms. Conditions other than pancreatic NETs can cause the symptoms listed below. Check with your doctor if you have any of these problems.

Signs and symptoms of a non-functional pancreatic NET

A non-functional pancreatic NET may grow for a long time without causing symptoms. It may grow large or spread to other parts of the body before it causes symptoms, such as:

  1. Diarrhea.
  2. Indigestion.
  3. A lump in the abdomen.
  4. Pain in the abdomen or back.
  5. Yellowing of the skin and whites of the eyes.

Signs and symptoms of a functional pancreatic NET

The symptoms of a functional pancreatic NET depend on the type of hormone being made.

Too much gastrin may cause:

  1. Stomach ulcers that keep coming back.
  2. Pain in the abdomen, which may spread to the back. The pain may come and go and it may go away after taking an antacid.
  3. The flow of stomach contents back into the esophagus (gastroesophageal reflux).
  4. Diarrhea.

Too much insulin may cause:

  1. Low blood sugar. This can cause blurred vision, headache, and feeling lightheaded, tired, weak, shaky, nervous, irritable, sweaty, confused, or hungry.
  2. Fast heartbeat.

Too much glucagon may cause:

  1. Skin rash on the face, stomach, or legs.
  2. High blood sugar. This can cause headaches, frequent urination, dry skin and mouth, or feeling
  3. hungry, thirsty, tired, or weak.
  4. Blood clots. Blood clots in the lung can cause shortness of breath, cough, or pain in the chest. Blood clots in the arm or leg can cause pain, swelling, warmth, or redness of the arm or leg.
  5. Diarrhea.
  6. Weight loss for no known reason.
  7. Sore tongue or sores at the corners of the mouth.

Too much vasoactive intestinal peptide (VIP) may cause:

  1. Very large amounts of watery diarrhea.
  2. Dehydration. This can cause feeling thirsty, making less urine, dry skin and mouth, headaches, dizziness, or feeling tired.
  3. Low potassium level in the blood. This can cause muscle weakness, aching, or cramps, numbness and tingling, frequent urination, fast heartbeat, and feeling confused or thirsty.
  4. Cramps or pain in the abdomen.
  5. Weight loss for no known reason.

Too much somatostatin may cause:

  1. High blood sugar. This can cause headaches, frequent urination, dry skin and mouth, or feeling hungry, thirsty, tired, or weak.
  2. Diarrhea.
  3. Steatorrhea (very foul-smelling stool that floats).
  4. Gallstones.
  5. Yellowing of the skin and whites of the eyes.
  6. Weight loss for no known reason.


Diagnosis

Lab tests and imaging tests are used to detect (find) and diagnose pancreatic NETs.

  1. Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  2. Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose (sugar), released into the blood by organs andtissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.
  3. Chromogranin A test: A test in which a blood sample is checked to measure the amount of chromogranin A in the blood. A higher than normal amount of chromogranin A and normal amounts of hormones such as gastrin, insulin, and glucagon can be a sign on a non-functional pancreatic NET.
  4. Abdominal CT scan (CAT scan): A procedure that makes a series of detailed pictures of the abdomen, taken from different angles. The pictures are made by a computer linked to an x-raymachine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  5. MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  6. Somatostatin receptor scintigraphy : A type of radionuclide scan that may be used to find small pancreatic NETs. A small amount of radioactive octreotide (a hormone that attaches to tumors) is injected into a vein and travels through the blood. The radioactive octreotide attaches to the tumor and a special camera that detects radioactivity is used to show where the tumors are in the body. This procedure is also called octreotide scan and SRS.
  7. Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An endoscope is a thin, tube-like instrument with a light and alens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
  8. Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope is passed through the mouth, esophagus, and stomach into the first part of the small intestine. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted into the duct to unblock it. This tube (orstent) may be left in place to keep the duct open. Tissue samples may also be taken and checked under a microscope for signs of cancer.
  9. Angiogram : A procedure to look at blood vessels and the flow of blood. A contrast dye is injected into the blood vessel. As the contrast dye moves through the blood vessel, x-rays are taken to see if there are any blockages.
  10. Laparotomy : A surgical procedure in which an incision (cut) is made in the wall of the abdomen to check the inside of the abdomen for signs of disease. The size of the incision depends on the reason the laparotomy is being done. Sometimes organs are removed or tissue samples are taken and checked under a microscope for signs of disease.
  11. Intraoperative ultrasound : A procedure that uses high-energy sound waves (ultrasound) to create images of internal organs or tissues during surgery. A transducer placed directly on the organ or tissue is used to make the sound waves, which create echoes. The transducer receives the echoes and sends them to a computer, which uses the echoes to make pictures called sonograms.
  12. Biopsy : The removal of cells or tissues so they can be viewed under a microscope by apathologist to check for signs of cancer. There are several ways to do a biopsy for pancreatic NETs. Cells may be removed using a fine or wide needle inserted into the pancreas during an x-ray or ultrasound. Tissue may also be removed during a laparoscopy (a surgical incision made in the wall of the abdomen).
  13. Bone scan : A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the blood. The radioactive material collects in bones where cancer cells have spread and is detected by a scanner.

Other kinds of lab tests are used to check for the specific type of pancreatic NETs.



Gastrinoma

  1. Fasting serum gastrin test: A test in which a blood sample is checked to measure the amount of gastrin in the blood. This test is done after the patient has had nothing to eat or drink for at least 8 hours. Conditions other than gastrinoma can cause an increase in the amount of gastrin in the blood.
  2. Basal acid output test: A test to measure the amount of acid made by the stomach. The test is done after the patient has had nothing to eat or drink for at least 8 hours. A tube is inserted through the nose or throat, into the stomach. The stomach contents are removed and four samples of gastric acid are removed through the tube. These samples are used to find out the amount of gastric acid made during the test and the pH level of the gastric secretions.
  3. Secretin stimulation test : If the basal acid output test result is not normal, a secretin stimulation test may be done. The tube is moved into the small intestine and samples are taken from the small intestine after a drug called secretin is injected. Secretin causes the small intestine to make acid. When there is a gastrinoma, the secretin causes an increase in how much gastric acid is made and the level of gastrin in the blood.
  4. Somatostatin receptor scintigraphy: A type of radionuclide scan that may be used to find small pancreatic NETs. A small amount of radioactive octreotide (a hormone that attaches to tumors) is injected into a vein and travels through the blood. The radioactive octreotide attaches to the tumor and a special camera that detects radioactivity is used to show where the tumors are in the body. This procedure is also called octreotide scan and SRS.

Insulinoma
  1. Fasting serum glucose and insulin test: A test in which a blood sample is checked to measure the amounts of glucose (sugar) and insulin in the blood. The test is done after the patient has had nothing to eat or drink for at least 24 hours.

Glucagonoma
  1. Fasting serum glucagon test: A test in which a blood sample is checked to measure the amount of glucagon in the blood. The test is done after the patient has had nothing to eat or drink for at least 8 hours.

VIPoma
  1. Serum VIP (vasoactive intestinal peptide) test: A test in which a blood sample is checked to measure the amount of VIP.
  2. Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. In VIPoma, there is a lower than normal amount of potassium.
  3. Stool analysis : A stool sample is checked for a higher than normal sodium (salt) and potassium levels.

Somatostatinoma
  1. Fasting serum somatostatin test: A test in which a blood sample is checked to measure the amount of somatostatin in the blood. The test is done after the patient has had nothing to eat or drink for at least 8 hours.
  2. Somatostatin receptor scintigraphy: A type of radionuclide scan that may be used to find small pancreatic NETs. A small amount of radioactive octreotide (a hormone that attaches to tumors) is injected into a vein and travels through the blood. The radioactive octreotide attaches to the tumor and a special camera that detects radioactivity is used to show where the tumors are in the body. This
  3. procedure is also called octreotide scan and SRS.

Staging

The plan for cancer treatment depends on where the NET is found in the pancreas and whether it has spread. The process used to find out if cancer has spread within the pancreas or to other parts of the body is called staging. The results of the tests and procedures used to diagnose pancreatic neuroendocrine tumors (NETs) are also used to find out whether the cancer has spread.

Although there is a standard staging system for pancreatic NETs, it is not used to plan treatment. Treatment of pancreatic NETs is based on the following:

  1. Whether the cancer is found in one place in the pancreas.
  2. Whether the cancer is found in several places in the pancreas.
  3. Whether the cancer has spread to lymph nodes near the pancreas or to other parts of the body such as the liver, lung, peritoneum, or bone.

Treatment
Overview:

Pancreatic NETs can often be cured. The prognosis (chance of recovery) and treatment options depend on the following:

  1. The type of cancer cell.
  2. Where the tumor is found in the pancreas.
  3. Whether the tumor has spread to more than one place in the pancreas or to other parts of the body.
  4. Whether the patient has MEN1 syndrome.
  5. The patient's age and general health.
  6. Whether the cancer has just been diagnosed or has recurred (come back).

Surgery

An operation may be done to remove the tumor. One of the following types of surgery may be used:

  1. Enucleation: Surgery to remove the tumor only. This may be done when cancer occurs in one place in the pancreas.
  2. Pancreatoduodenectomy: A surgical procedure in which the head of the pancreas, the gallbladder, nearby lymph nodes and part of the stomach, small intestine, and bile duct are removed. Enough of the pancreas is left to make digestive juices and insulin. The organs removed during this procedure depend on the patient's condition. This is also called the Whipple procedure.
  3. Distal pancreatectomy: Surgery to remove the body and tail of the pancreas. The spleen may also be removed.
  4. Total gastrectomy: Surgery to remove the whole stomach.
  5. Parietal cell vagotomy: Surgery to cut the nerve that causes stomach cells to make acid.
  6. Liver resection: Surgery to remove part or all of the liver.
  7. Radiofrequency ablation: The use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia.
  8. Cryosurgical ablation: A procedure in which tissue is frozen to destroy abnormal cells. This is usually done with a special instrument that contains liquid nitrogen or liquid carbon dioxide. The instrument may be used during surgery or laparoscopy or inserted through the skin. This procedure is also called cryoablation.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into avein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is the use of more than one anticancer drug. The way the chemotherapy is given depends on the type of the cancer being treated.



Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working.



Chemoembolisation

Hepatic arterial occlusion uses drugs, small particles, or other agents to block or reduce the flow ofblood to the liver through the hepatic artery (the major blood vessel that carries blood to the liver). This is done to kill cancer cells growing in the liver. The tumor is prevented from getting the oxygen andnutrients it needs to grow. The liver continues to receive blood from the hepatic portal vein, which carries blood from the stomach and intestine.

Chemotherapy delivered during hepatic arterial occlusion is called chemoembolization. The anticancer drug is injected into the hepatic artery through a catheter (thin tube). The drug is mixed with the substance that blocks the artery and cuts off blood flow to the tumor. Most of the anticancer drug is trapped near the tumor and only a small amount of the drug reaches other parts of the body.

The blockage may be temporary or permanent, depending on the substance used to block the artery.



Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Certain types of targeted therapies are being studied in the treatment of pancreatic NETs.



Supportive care

Supportive care is given to lessen the problems caused by the disease or its treatment. Supportive care for pancreatic NETs may include treatment for the following:

  1. Stomach ulcers may be treated with drug therapy such as:
    1. Proton pump inhibitor drugs such as omeprazole, lansoprazole, or pantoprazole..
    2. Somatostatin-type drugs such as octreotide.
  1. Diarrhea may be treated with:
    1. Intravenous (IV) fluids with electrolytes such as potassium or chloride.
    2. Somatostatin-type drugs such as octreotide.
  2. Low blood sugar may be treated by having small, frequent meals or with drug therapy to maintain a normal blood sugar level.
  3. High blood sugar may be treated with drugs taken by mouth or insulin by injection.

Treatment Options for Specific Pancreatic Neuroendocrine Tumors
Gastrinoma:

Treatment of gastrinoma may include the following:

  1. For symptoms caused by too much stomach acid, treatment may be a drug that decreases the amount of acid made by the stomach.
  2. For a single tumor in the head of the pancreas:
    1. Surgery to remove the tumor.
    2. Surgery to cut the nerve that causes stomach cells to make acid and treatment with a drug that decreases stomach acid.
    3. For a single tumor in the body or tail of the pancreas, treatment is usually surgery to remove the body or tail of the pancreas.
  3. For several tumors in the pancreas, treatment is usually surgery to remove the body or tail of the pancreas.
  4. For one or more tumors in the duodenum (the part of the small intestine that connects to the stomach), treatment is usually pancreatoduodenectomy (surgery to remove the head of the pancreas, the gallbladder, nearby lymph nodes and part of the stomach, small intestine, and bile duct).
  5. If the cancer has spread to the liver, treatment may include:
    1. Surgery to remove part or all of the liver.
    2. Radiofrequency ablation or cryosurgical ablation.
    3. Chemoembolization.
  6. If cancer has spread to other parts of the body or does not get better with surgery or drugs to decrease stomach acid, treatment may include:
    1. Chemotherapy.
    2. Hormone therapy.
  7. If the cancer mostly affects the liver and the patient has severe symptoms from hormones or from the size of tumor, treatment may include:
    1. Hepatic arterial occlusion, with or without systemic chemotherapy.
    2. Chemoembolization, with or without systemic chemotherapy.

Insulinoma

Treatment of insulinoma may include the following:

  1. For one small tumor in the head or tail of the pancreas, treatment is usually surgery to remove the tumor.
  2. For one large tumor in the head of the pancreas that cannot be removed by surgery, treatment is usually pancreatoduodenectomy (surgery to remove the head of the pancreas, the gallbladder, nearby lymph nodes and part of the stomach, small intestine, and bile duct).
  3. For one large tumor in the body or tail of the pancreas, treatment is usually a distal pancreatectomy (surgery to remove the body and tail of the pancreas).
  4. For more than one tumor in the pancreas, treatment is usually surgery to remove any tumors in the head of the pancreas and the body and tail of the pancreas.
  5. For tumors that have spread to lymph nodes or other parts of the body, treatment may include the following:
    1. Surgery to remove the tumor.
    2. Radiofrequency ablation or cryosurgical ablation, if the tumor cannot be removed by surgery.
  6. For tumors that cannot be removed by surgery, treatment may include the following:
    1. Combination chemotherapy.
    2. Palliative drug therapy to decrease the amount of insulin made by the pancreas.
    3. Hormone therapy.
    4. Radiofrequency ablation or cryosurgical ablation.
  7. If the cancer mostly affects the liver and the patient has severe symptoms from hormones or from the size of tumor, treatment may include:
    1. Hepatic arterial occlusion, with or without systemic chemotherapy.
    2. Chemoembolization, with or without systemic chemotherapy.

Glucagonoma

Treatment may include the following:

  1. For one small tumor in the head or tail of the pancreas, treatment is usually surgery to remove the tumor.
  2. For one large tumor in the head of the pancreas that cannot be removed by surgery, treatment is usually pancreatoduodenectomy (surgery to remove the head of the pancreas, the gallbladder, nearby lymph nodes and part of the stomach, small intestine, and bile duct).
  3. For more than one tumor in the pancreas, treatment is usually surgery to remove the tumor or surgery to remove the body and tail of the pancreas.
  4. For tumors that have spread to lymph nodes or other parts of the body, treatment may include the following:
    1. Surgery to remove the tumor.
    2. Radiofrequency ablation or cryosurgical ablation, if the tumor cannot be removed by surgery.
  5. For tumors that cannot be removed by surgery, treatment may include the following:
    1. Combination chemotherapy.
    2. Hormone therapy.
    3. Radiofrequency ablation or cryosurgical ablation.
  6. If the cancer mostly affects the liver and the patient has severe symptoms from hormones or from the size of tumor, treatment may include:
    1. Hepatic arterial occlusion, with or without systemic chemotherapy.
    2. Chemoembolization, with or without systemic chemotherapy.

VIPoma

treatment may include the following:

  1. Fluids and hormone therapy to replace fluids and electrolytes that have been lost from the body.
  2. Surgery to remove the tumor and nearby lymph nodes.
  3. Surgery to remove as much of the tumor as possible when the tumor cannot be completely removed or has spread to distant parts of the body. This is palliative therapy to relieve symptoms and improve the quality of life.
  4. For tumors that have spread to lymph nodes or other parts of the body, treatment may include the following:
    1. Surgery to remove the tumor.
    2. Radiofrequency ablation or cryosurgical ablation, if the tumor cannot be removed by surgery.
  5. For tumors that continue to grow during treatment or have spread to other parts of the body, treatment may include the following:
    1. Chemotherapy.
    2. Targeted therapy.

Somatostatinoma

treatment may include the following:

  1. Surgery to remove the tumor.
  2. For tumors that have spread to distant parts of the body, surgery to remove as much of the tumor as possible to relieve symptoms and improve quality of life.
  3. For tumors that continue to grow during treatment or have spread to other parts of the body, treatment may include the following:
    1. Chemotherapy.
    2. Targeted therapy.

Over-view of Cancer Surgery
Goal of Cancer Surgery

Depending on your cancer type and stage, our goals for treatment are:

Cure. This is the most important goal of cancer surgery. In fact as a cancer patient you are also strongly willing to have cure of cancer for forever. For most of the Liver & Gastro-intestinal cancers perhaps surgery is the first step for cure. Radiation &/or Chemotheray may be advised as an additional tool to achieve this goal.  

Control. If your cancer is at a later stage or if previous treatments have been unsuccessful, we aim to control your cancer by removing as much as safely possible. Once you recover from surgery, radiation or chemotherapy is advised as important tool to control your cancer.

Comfort. If you have an advanced stage of cancer or one that hasn't responded to treatments and having symptoms because of tumor i.e pain, jaundice, vomiting, bleeding either in vomitus or in stool, then our multi-specialist team work together to sure you are free of pain and other symptoms



Role of Surgery for Cancer treatment

Surgery can be done for many reasons for treatment of cancer.

Curative Surgery

Curative surgery is done when cancer is found in only one area, and it’s likely that all of the cancer can be removed. In this case, curative surgery can be the main treatment. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation.

Diagnostic & Staging Surgery

This type of surgery is used to take out a piece of tissue (biopsy) to find out if cancer is present or what type of cancer it is. The diagnosis of cancer is made by looking at the cells under a microscope. Staging surgery is done to find out how much cancer there is and how far it has spread. The physical exam and the results of lab and imaging tests are used to figure out the clinical stage of the cancer. But the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. Examples of surgical procedures commonly used to stage cancers, like laparoscopy or laparotomy.

Palliative Surgery

This type of surgery is used to treat problems caused by advanced cancer. It is not done to cure the cancer. For example, cancers of intestine may grow large enough to block off (obstruct) the intestine, or tumor is bleeding and unable to control bleed by medical/endoscopic technique. If this happens, surgery can be used to remove the blockage/control bleeding.



Approach for Surgery:

How surgery is performed? (Special surgery techniques): Open Or Laparoscopic

Open Surgery:

It is the Gold Standard approach for Liver & Gastro-Intestinal cancer. An incision is given on the belly depending upton the underlying location of tumor so that surgeon can directly approach the cancer on cutting the belly. Open Surgery help to remove tumor safely if its adherent to near by blood vessels or organ, that is otherwise difficult in laparoscopic surgery.

Laparoscopic Surgery

A laparoscope is a long, thin, flexible tube that can be put through a small cut (incision) to look inside the body. In recent years, doctors have found that by creating small holes and using special instruments, the laparoscope can be used to perform surgery without making a large cut. This can help reduce blood loss during surgery and pain afterward. It can also shorten hospital stays and allow people to heal faster.

The role of laparoscopic surgery in cancer treatment is not yet clear. Doctors are now studying whether it is safe and effective to use laparoscopic surgeries for cancers of the stomach, colon, rectum & liver. It may prove to be as safe and work as well as standard surgery while cutting less and causing less damage to healthy tissues (being less invasive).



Biopsy of Cancer before Surgery

Biopsy is procedure to confirm the presence of cancer. It’s not essential before surgery. Usually biopsy is performed when 1. Suspicion is cause other than cancer, 2. When surgery cannot be done for cancer due to advanced stage of cancer or 3. Patient is unfit to undergo surgery. In these situation, biopsy guides for further therapy.

If all investigations suggest that cancer can be removed in totality from body, then biopsy can be avoided in to minimize the risk of spillage of cancer cell during biopsy procedure.

There is variety of way to perform biopsies:

1. Fine Needle Aspiration (FAN) biopsy

  1. Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out small bits of tissue. The needle is guided into the tumor by looking at it using an imaging test, like an ultrasound or CT scan.
  2. The main advantage of FNA is that there is no need to cut through the skin, so there is no surgical incision.
  3. A drawback is that in some cases the needle can’t take out enough tissue for an exact diagnosis. A more invasive type of biopsy (one that involves larger needles or a cut in the skin) may then be needed.

2 .Core Needle biopsy

  1. This type of biopsy uses a larger needle to take out a core of tissue and done under guidance of imaging test like an ultrasound or CT scan. The advantage of core biopsy is that it usually collects enough tissue to find out whether the tumor is cancer.

3 .Excisional or Incisional biopsy

  1. For these biopsies, the surgeon remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy).

Know about Surgery
Preparation for Surgery

Our expert team members shall help you to prepare you for surgery. You are strongly advised to stop smoking, stop drinking alcohol, try to improve your diet, lose weight, or actively exercise before surgery.

Pre-operative testing

In most cases, you will need some tests before your surgery. The tests routinely used include:

  1. Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working. Your blood group type is also be checked in case you need blood transfusions during the operation.
  2. Chest x-ray and ECG (electrocardiogram) to check your lungs and your heart’s electrical system.
  3. USG/CT scans/ MRI to look at the size and location of the tumors and see if the cancer looks like it has spread to nearby tissues.

Anaesthetic Assessment before Surgery:

Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you’ve had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped 1 week prior to surgery.

Informed Consent

Informed consent is one of the most important parts of “getting ready for surgery”. It is a process during which you are told about all aspects of the treatment before you give your doctor written permission to do the surgery.

Getting ready for Surgery

Depending on the type of operation you have, there may be things you need to do to be ready for surgery:

  1. Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomit could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery.
  2. Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
  3. Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.

Anaesthesia

Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel “out of it” for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.



Recovery from Surgery

Your recovery right after surgery depends on many factors, including your state of health before the operation and how extensive the operation was performed.

Pain

You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).

Tube/ Drains

You may also have Ryle’s Tube (tube going through nose to stomach) that drain out intestinal fluid. This tube helps to relieve nausea and vomiting after surgery and usually removed 1-2 day after surgery.

You may also have “Tube” (called a Foley catheter) draining urine from your bladder into a bag. This will be taken out soon after surgery, once you are comfortable enough to go to bathroom.

You may have a tube or tubes (called Drains) coming out of the surgical opening in your skin (incision site). Drains allow the excess fluid that collects at the surgery site to leave the body. Drain tube will also be removed once they stop collecting fluid, usually a few days after the operation.

Leg Stocking / Compression boot

As you are remains in bed on day of surgery, circulation of blood in leg become sluggish that may increase possibility of thrombo-embolism. To minimise it, you will be wearing leg stocking/ pneumatic compression boot to improve your leg circulation thus minimising the risk of thrombolism.

Eating and Drinking

You may not feel much like eating or drinking, but this is an important part of the recovery process. Our health care team may start you out with ice chips or clear liquids. The stomach and intestines (digestive tract) is one of the last parts of the body to recover from the drugs used during surgery. You will need to have signs of stomach and bowel activity before you will be allowed to eat. You will likely be on a clear liquid diet until this happens. Once it does, you may get to try solid foods.

Activity

Our health care team will try to have you move around as soon as possible after surgery. They may even have you out of bed and walking the same day. While this may be hard at first, it helps speed your recovery by getting your digestive tract moving. It also helps your circulation and helps prevent blood clots from forming in your legs.

Our team shall also encourage you to do deep breathing exercises. This helps fully inflate your lungs and reduces the risk of pneumonia. You are advised to take deep breaths and cough every hour to help prevent lung infections. You will use an incentive spirometer (a small device used in breathing exercises to prevent complications after major surgery) 10-15 times every hour.

Going home

Once you are eating and walking, all tube/drains placed during surgery are removed, and then you may be ready to go home. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment.



Risks and Side effects of Surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What’s important is whether the expected benefits outweigh the possible risks.

Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:

  1. Complications related to Anaesthesia: Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures. Your doctors will watch your heart rate, breathing rate, blood pressure, and other signs throughout the procedure to look for this.
  2. Complications related to underlying medical illness like heart disease, diabetes, kidney disease, obesity, malnutrition.
    1. Lung: Pneumonia, Atelectasis (collapse of lung), effusion (fluid in chest) can occur, especially in patients with reduced lung function, such as smokers. Doing deep breathing exercises as soon as possible after surgery helps lessen this risk.
    2. Thrombosis (blood clot) in leg & embolism (blood clot) in lung. Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.
    3. Cardiovascular: Myocardial infarction (heart attach), Arrhythmia (irregular heart beat), Stroke (cerebro-vascular accidents)
    4. Kidney & urinary tract infection, acute kidney failure if patient has uncontrolled/non-responding infection
  3. Complications related to Specific Operations
    1. There are specific complications related to type of surgery. You are encouraged with discuss in detail with our health care team before you give your consent for surgery.
    2. Bile leak
    3. Bleed
  4. Complications related to Major Surgery
    1. Infection: Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.
    2. Bleeding: The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.
    3. Leakage from anastomosis (joint of anastomosis) & fluid collection in tummy
    4. Blockage of intestine (Intestinal obstruction)

Life after Surgery

Nutrition: Following treatment, you may feel change in your taste. This improves over a time and we encourage having health food habit like fresh vegetables, fruits and high protein diet.


Exercise: Along with healthy food habits, we also encourage for exercise. Exercise improves your health in different ways: It improves your heart and circulation, makes your muscles stronger & makes you feel happier. You should do your regular activities like walking, and rather increase day by day. Weight lifting and strenuous exercise are avoided for initial 2-3 months.

Follow up care: You'll need regular checkups after treatment for pancreatic neuro-endoscrine cancer. This help to find out any change in your recovery. Sometimes liver cancer comes back after treatment. Our health care team will check for return of cancer. Checkups may include a physical exam, blood tests, ultrasound / CT scan.

If you have any health problems between checkups, you should contact our health care team. Report to our health care team, if you have any redness/ swelling or discharge of any type of fluid from your operative incision site, pain abdomen, vomiting or fever, breathing difficulty etc.

 
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