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Nutrition Implications of Pancreatic Cancer
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Sodexo Dietetic Internship
Andrea Young
Abstract
Pancreatic cancer is the fourth leading cause of cancer related deaths in the United States.
The detection of pancreatic cancer typically occurs during advanced stages, causing the
prognosis to be poor. Cancer and cancer treatments have many nutritional implications; with the
advice of a Registered Dietitian nutritional complications can be minimized and help improve a
patient’s quality of life. Upon meeting several patients with pancreatic cancer and knowing little
about the condition, I decided to research the topic and find what a Registered Dietitian can do to
help these individuals. Patient centered care with goals and advice that are realistic and
achievable can help a patient improve their nutrition status and possibly minimize adverse
effective from cancer and cancer treatments.
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Introduction
After meeting patients in the acute care setting at St. Mary’s Medical Center with
pancreatic cancer I became interested in the disease and the complications that may arise from
the cancer and the treatments. Having not previously known about pancreatic cancer and its poor
prognosis gave me further interest in researching the topic in detail. Being up to date on different
treatment options available can help guide the Registered Dietitian to different nutrition
implications that can occur. By taking a more detailed look into pancreatic cancer I hoped to
learn about current treatments and nutritional advice that can be provided to patients.
Normal Anatomy and Physiology of the Pancreas
The pancreas is a slender complex organ ranging in length from six to nine inches.
Located below the liver and posterior of the stomach the pancreas consists of a head, located
within the curvature of the duodenum, a body, and a tail, which extends to the spleen. There are
two types of active cells within the pancreas consisting of endocrine and exocrine tissues. (1, 2)
Refer to figure 1 in the appendix.
The endocrine portion of the pancreas consists of the islets of Langerhan, which primarily
secretes the hormones insulin and glucagon into the blood. Alpha cells of the pancreatic islet
secrete glucagon and the beta cells secrete insulin. (1) Endocrine glands do not have ducts but
rather have extensive blood vessels in the connective tissue of the glands; the hormones secreted
by endocrine glands are secreted into the bloodstream. Acinar glands compose the exocrine
portion of the pancreas and produces digestive enzymes, which are packaged into granules and
released into the pancreatic juice. Clusters of acini cells form lobules, which secrete digestive
enzymes into a network of ducts, these ducts join the main pancreatic duct known as the Wirsung
Duct, which runs the length of the pancreas. (2)
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Ducts are structures that carry fluids within the body and resemble tubes. The pancreas
and gallbladder share a duct for entry into the duodenum. Bile ducts carry bile, made in the liver,
to the gallbladder. When a food is consumed the gallbladder releases bile into a common bile
duct. The pancreatic duct joins the common bile duct at the hepatopancreatic ampulla, which
empties into the duodenum at the major duodenal papilla. The hepatopancreatic ampullar
sphincter also known as the sphincter of Oddi regulates the opening of the ampulla into the
duodenum. (1, 3)
The parasympathetic nervous system and hormones stimulate the pancreas to release
pancreatic juice. The hormone secretin is secreted by the proximal small intestine in response to
the release of acidic chyme into the duodenum. The pancreas is stimulated by the secretin to
secrete water, bicarbonate, and pancreatic enzymes into the duodenum. Cholecystokinin
stimulates the release of bile from the gallbladder and stimulates the pancreas to secrete
pancreatic juice and enzymes into the duodenum. (2) The presence of fatty acids and other lipids
in the duodenum is the major stimulus for the release of cholecystokinin.(1) Vasoactive intestinal
polypeptide is located within the neurons of the small intestine and stimulates the pancreas to
release bicarbonate into the small intestine. Somatostatin is a hormone that inhibits pancreatic
exocrine secretions. Insulin release is inhibited by Amylin, galanin, as well as somatostatin,
where as glucose-dependent insulinotropic polypeptide and glucagon-like peptide stimulate
insulin secretions. (2)
Functions of the Pancreas
Endocrine and exocrine cells are the main component of the pancreas giving the pancreas
hormonal and digestive functions. Insulin, amylin, glucagon, pancreatic polypeptide and
somatostatin are the hormones secreted by the pancreas. (1) The role of insulin and glucagon will
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be reviewed in this section. The pancreas secretes insulin when increased levels of glucose are
within the blood; insulin is an anabolic hormone involved in glucose, lipid, and amino acid
synthesis and storage. Insulin inhibits the expression of catabolic hormones, which would
catabolize glucose, lipids, and proteins. When serum glucose levels drop the pancreas releases
glucagon into the blood. Glucagon stimulates the catabolism of stored glucose, lipids, and
proteins within the body for energy. (2, 3)
Pancreatic juice, which is the exocrine secretion of the pancreas, has two major
components, an aqueous component and an enzymatic component. Pancreatic juice is delivered
to the small intestine where its function is digestion. The aqueous component of pancreatic juice
contains sodium and potassium as well as bicarbonate. The bicarbonate ions are a major part of
the aqueous component and neutralize the acidic chyme coming from the stomach. Pancreatic
secretions increase the pH of the duodenum providing the proper environment for the function of
pancreatic enzymes. (1, 2)
Acinar cells of the pancreas produce the enzymes of the pancreatic juice. (1) The
enzymes produced allow for adequate digestion of protein, carbohydrates, and lipids; these
enzymes released by the pancreas digest about 50% of ingested protein, 50% of indigested
carbohydrates, and 80-90% of ingested fats. (2) Proteolytic enzymes include trypsin,
chymotrypsin, and carboxypeptidase; these enzymes are secreted in their inactive form to
prevent digestion of the tissues, which produce them. Pancreatic amylase digests polysaccharides
and lastly pancreatic lipases break down lipids into monoglycerides, free fatty acids, and
cholesterol. (1)
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Process of Cancer
Cancer begins with cell growth that is abnormal and out of control. Cells are what build
tissues and tissues form organs. When cells become cancerous they can affect the tissues that
them make up. Normal cells grow, divide, and die. DNA is in every cell and is what directs the
cells actions. When normal cells have damaged DNA the cell repairs the damage or the cell dies.
Cancer cells have damaged DNA, these cells are not repaired and do not die but rather multiply
with the same damaged DNA. (3) Refer to figure 2 in the appendix. (4)
Cancer is able to invade other tissues, shed cancer cells, or spread to other organs.
Invasion occurs when a malignant tumor grows and invades near by organs. When cancer cells
break off from the main tumor the cancer cells are shedding, this may lead to new tumor
formation on the surface of nearby organs and tissues. Cancer is considered to have spread when
cancer cells break off from the original tumor and spread through the circulatory or lymphatic
system, once the cancer has spread the cancer cells can attached to and grow on different tissues.
When cancer has invaded, shed, or spread to other tissues it is considered to have
metastasized.(4)
Cancer Staging
Staging of cancer is done to determine the severity of an individual’s cancer and
generally covers the extent of the tumor, whether the tumor has spread to the lymph nodes, and
whether metastasis has occurred. This method of staging is used by the National Cancer Institute
and is termed the TNM system, the letters representing tumor, lymph nodes, and metastasis.
Using the TNM system a number is added to each letter indicating size or extent of the primary
tumor and the extent of the cancer spread. For TNM staging see table 1 in the appendix. (4)
TNM staging combinations correspond to one of five stages for many caners. In general Stage 0
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indicates carcinoma in situ; Stage I, Stage II, and Stage III indicate more extensive cancer
including a larger tumor size and possible spreading of the cancer, beyond the organ in which it
first developed, to nearby lymph nodes or organs adjacent to the location of the primary tumor.
Stage IV cancer typically has spread to another organ. (4)
Pancreatic Cancer
About 60% of pancreatic tumors originate in the head of the pancreas, 15% in the body,
and 5% in the tail, 20% are diffuse within the pancreas. There are two main types of pancreatic
cancer; the most common type is exocrine pancreatic cancer, which starts in the ducts that carry
pancreatic juices. Endocrine pancreatic cancer, also known as islet cell cancer, is less common
and begins within the cells that make hormones. Cancer of the pancreas is a broad definition
because as many as twenty different types of tumors are categorized under the term pancreatic
cancer. Different tumors of the pancreas have different treatments because of each tumors unique
prognosis. See table 2 in the appendix for types of pancreatic tumors. Primary and metastatic are
two broad ways to classify pancreatic caner. Primary pancreatic cancer refers to cancer arising
from the pancreas where as metastatic pancreatic cancer refers to cancer originating in other
organs and later spreading to the pancreas. Primary pancreatic cancer is typical in the majority of
cases and can be sub-grouped into cancers showing endocrine differentiation and those that do
not. (4, 5, 6)
Epidemiology of Pancreatic Cancer
Pancreatic cancer is the fourth leading cause of cancer related deaths within the United
States. Incidence rates seem to be increasing due to pancreatic cancer becoming more common
as well as the difficulty in diagnosing until in advanced stages. It was estimated that within the
year 2012 43,920 individuals would be diagnosed with pancreatic cancer, and 37,390 deaths
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would occur due to pancreatic cancer. Survival from pancreatic cancer is poor compared to other
cancers; only 6% of pancreatic cancer patients live more than 5 years after diagnosis. Survival
rates are generally low with pancreatic cancer due to delayed diagnosis and metastasis of
cancer.(7)
The cause of pancreatic cancer is unknown, however it is believed genetics plays a major
role. Lifestyle factors may also play a major role in the development of pancreatic cancer; some
of these factors include, smoking, exposure to chemicals such as gasoline and fuel oils, as well as
being obese and consuming a diet high in red meat or low in fruits and vegetables; doses of
alcohol greater than 30 grams per day contributes to only a modest increase. Other risk factors
for pancreatic cancer include older age, males, African American, family history, cirrhosis, and
chronic pancreatitis. Type II diabetes is not a true risk factor. Although risk factors can increase
an individual’s risk of developing cancer, risk factors do not cause the disease. People with none
of these risk factors could still develop pancreatic cancer. (8, 9)
Signs and Symptoms
Symptoms of pancreatic cancer typically occur once the cancer has progressed to
advanced stages. Each individual can experience the common symptoms that occur differently.
Severe abdominal pain, which radiates into the back, is a common symptom of most patients.
Weight loss due to malignant cancer cells depriving healthy cells of nutrients, as well as
digestive problems, which may occur due to the pancreas’ integral part of digestion are common
in pancreatic cancer patients. (9, 10) Nausea and vomiting can occur during advanced stages of
pancreatic caner, this can occur when the tumor grows large enough to block part of the digestive
tract, typically the duodenum. (7) Diabetes occurs in 25-50% of patients and may lead to
symptoms of glucose intolerance such as polyuria and polydipsia. Jaundice, a yellowing of the
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skin and whites of the eyes, occurs in about 80-90% of patients with adenocarcinomas of the
head of the pancreas. Jaundice occurs when a tumor blocks the flow of bile, when blood cells
break down into bilirubin once worn out, bilirubin is eliminated into the bile, if the flow of bile is
obstructed jaundice occurs. Severe itching may also occur due to the build up of bile acids. When
cancer is in the body and tail of the pancreas splenic vein obstruction can occur leading to
splenomegaly, gastric and esophageal varices, and GI hemorrhage. Because many of these
symptoms occur late in diagnosis 90% of patients have locally advanced tumors, cancer has
spread to regional lymph nodes or metastasized to the liver or lungs. (10)
Diagnosis of Pancreatic Cancer
Pancreatic cancer can be difficult to diagnose. As stated before symptoms do not
typically arise until advanced stages and many symptoms may be mistaken as signs of other
conditions. The pancreas is also located deep behind other organs and can be difficult to see and
assess without proper equipment. The first step of diagnosing is to determine the size and extent
of the pancreatic tumor; this will ensure the most appropriate and effective treatment. There are
many ways to diagnose a patient with pancreatic cancer including physical exam, imaging, blood
test, biopsy, as well as several other methods. The doctor may first start with a physical exam of
the patient, feeling the abdomen for abnormal changes around the pancreas, liver, gallbladder,
and spleen; checking for abdominal fluid buildup is also common as well as checking the skin
and eyes for signs of jaundice. Although a physical exam will not confirm diagnosis of
pancreatic cancer it can be a starting point to initiate further testing to be completed. (4, 11, 12,
13)
Blood tests can be completed to help support a diagnosis of pancreatic caner as well as
monitor the progression of the disease and the effects of treatment. Hepatic function tests can be
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completed to assess levels of bilirubin and liver enzymes. Higher bilirubin levels can indicate a
blockage of the bile duct, however pancreatic cancer is not the only cause of increased bilirubin
levels. Another blood test is the CA 19-9, which is a tumor marker. CA 19-9 is an antigen
existing on the surface of cancer cells. Elevated levels of CA 19-9 can indicate a presence of a
pancreatic mass or biliary obstruction, and may support pancreatic cancer as a diagnosis.
However CA-19-9 can be elevated for multiple reasons and cannot be used alone to make a
diagnosis. (12, 14)
Diagnostic imaging is important and needed to determine the extent of the tumor and
whether cancer cells have spread to other tissues. Several imaging tests can be done including the
CT scan, MRI, MRCP, EUS, and ERCP. Computer tomography scan, which is abbreviated CT
scan, is done to identify the location of a tumor and the extent of the pancreatic tumor. The scan
allows for a detailed picture of the pancreas and nearby organs, and blood vessels. (4, 12)
Magnetic resonance imaging, or MRI, is another type of imaging used; this procedure uses large
magnetic radiofrequency to create a detailed image of the pancreas. Magnetic resonance
cholangiopancreatography, abbreviated MRCP, is a type of MRI, this is used to create an image
of the pancreatic ducts and channels in the pancreas. An endoscopic ultrasound, also known as
EUS, can be done to provide a detailed picture of the pancreas and remove pancreatic cells and
fluid for a biopsy. The EUS procedure is completed by inserting an endoscope through the mouth
down to the stomach, at the end of the endoscope is an ultrasound probe. The endoscopic
retrograde cholangiopancreatography, also known as ERCP, is another type of imaging that can
be done. This procedure allows for images of the pancreatic duct, which allow the physician to
determine if the ducts have narrowed or have become blocked. The ERCP also allows for
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removal of pancreatic cells for biopsy and to guide for placement of a bile duct stent to relieve
jaundice. (4, 6, 11, 12)
The findings of the imaging techniques can determine the diagnostic technique to be used
next. Percutaneous needle aspiration of an accessible lesion may be considered for tissue
diagnosis if the CT or MRCP shows unresectable or metastatic disease. MRCP or endoscopic
ultrasound may be used to stage pancreatic cancer or detect small tumors unseen by a CT scan;
this is done when the CT scan shows a possible resectable tumor or no tumor. ERCP may be
used as a first diagnostic procedure if a patient has obstructive jaundice. (10, 11)
After having a physical examination, laboratory work, and imaging test, a biopsy is the
next tool needed. Biopsy remains the gold standard for diagnosing pancreatic cancer. The biopsy
is important to determine the type of tumor that is present, there are about 20 different types of
tumors and each responds differently to different types of treatment. The endoscopic ultrasound
and the endoscopic retrograde cholangiopancreatography are the most common techniques for
biopsy. A laparoscopic procedure can also be performed to obtain a biopsy; this procedure is
completed by inserting a laparoscope through the abdomen, allowing for a visual of the pancreas
as well as the ability to remove a small amount of tissue and fluid. (11, 12)
The best treatment option is chosen after learning the extent or stage of the cancer. Often
times a laparotomy is performed to view the extent of the pancreatic tumor and determine
whether successful removal of the tumor would be possible without causing undue harm to the
patient. Once all the procedures have been completed the stage is typically able to be determined.
When staging cancer tumor size, whether the tumor has invaded nearby tissue, and whether the
cancer has spread are considered. (4, 12)
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Pancreatic Cancer Staging
Stage 0 is pancreatic carcinoma in situ. The tumor at this stage remains of the surface of
the pancreatic duct cells; the cancer has not invaded deeper tissue or spread outside of the
pancreas. Stage IA pancreatic cancer indicates the tumor is less than 2cm and is contained
within the pancreas. Stage IB indicates the tumor is greater than 2cm and is contained within the
pancreas. Stage IIA pancreatic cancer indicates the tumor has begun to grow outside the
pancreas. At this stage the cancer has not spread to lymph nodes, major blood vessels, or distant
sites. Stage IIB indicates the tumor is confined to the pancreas or growing outside the pancreas.
At this stage the cancer has not spread into nearby large blood vessels, major nerves, or distant
sites but has spread to nearby lymph nodes. Stage III pancreatic cancer indicates the tumor is
growing outside of the pancreas and within nearby large blood vessels or major nerves, it may or
may not have spread to nearby lymph nodes but has not spread to distant sites. Stage IV
pancreatic cancer indicates the cancer has spread to near by organs such as the liver, lungs or
peritoneum. (3, 6, 12)
Treatment options for pancreatic cancer depend on the stage of the cancer. Stages IA and
IB are local and resectable, meaning because the cancer is only in the pancreas or has spread just
beyond the pancreas a surgeon can remove the entire tumor. Stages IIA and IIB are locally
advanced and potentially resectable. Stage III is locally advanced and unresectable. When using
the term locally advanced it indicates the cancer has not yet spread to distant organs but still
cannot be completely removed, many times the cancer cannot be removed due to the cancer
being present in nearby blood vessels. If surgery is done it is typically to relieve symptoms or
problems such as blocked bile ducts. Lastly Stage IV is metastatic and unresectable. When the
cancer is metastatic, surgery is typically done to relieve symptoms and not for a cure. (3,15)
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Treatment
Treatment options for pancreatic cancer include surgery, chemotherapy, targeted therapy,
radiation therapy and symptomatic therapies. As stated previously, pancreatic cancer diagnosis
tends to occur in advanced stages and treatment strategies tend to exclude surgery. Only a small
percentage of pancreatic cancer patients have surgery. The surgeries that are available include
the Whipple procedure, distal pancreatectomy, and total pancreatectomy. Although treatments
are available, the prognosis of pancreatic cancer remains poor. (9)
Surgery
The Whipple procedure, also called a pancreaticoduodenectomy, is the most common
surgery for pancreatic cancer. This procedure is done to remove cancer that is in the head of the
pancreas; the surgery also removes part of the small intestine, the lower half of the bile duct, the
surrounding lymph nodes, the gallbladder, and the pylorus. Part of the portal vein may also be
removed if it has been invaded by the pancreatic tumor. The surgeon then reconnects the
remaining pancreas, stomach, and bile duct to the small intestine allowing for the pancreatic
digestive enzymes, bile, and stomach contents to flow into the small intestine during digestion. If
the pylorus is preserved and not removed the surgery is called a pylorus preserving Whipple. The
most common complication following the Whipple procedure is gastroparesis, which occurs on
average for 7-10 days but can occur up to a few weeks following the procedure. In 10% of
patients serious abdominal infection occurs due to a fistula, which causes leakage, where the
pancreas has been connected to the intestine, this typically requires draining tubes, antibiotics,
and supplemental feedings. Long-term effects including digestive difficulties may occur
following the Whipple procedure. (12, 15)
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The distal pancreatectomy is performed in patients with exocrine tumors located in the
tail of the pancreas. In this procedure the tail of the pancreas is removed, sometimes part of the
body of the pancreas is also removed as well as the spleen. Pancreatic juice leaking is the most
common complication of this surgery. Serious complications include leakage and infection.
(12,15)
Total pancreatectomy is rarely performed but is done when the entire pancreas, head,
body, and tail have been invaded by the tumor. In addition to the entire pancreas being removed
the gallbladder, pylorus, duodenum, lower half of the bile duct, nearby lymph nodes, and
occasionally the spleen are removed. Due to the removal of the entire pancreas the patient will be
diabetic following the procedure and must use insulin to control blood glucose. The patient will
also require pancreatic enzymes to be taken with food for appropriate digestion. (12,15)
Chemotherapy
Surgery as previously states is not for all patients, however many times chemotherapy is
used in conjunction with radiation and surgery to provide the most optimal outcomes.
Chemotherapy can be used alone but often is used in conjunction with other treatments such as
radiation therapy. Chemotherapy is a systemic treatment attacking all rapidly dividing cells in the
body by preventing them from growing and dividing, including cancer cells and healthy cells.
Chemotherapy can prevent pancreatic tumors from growing and sometimes shrinks them.
Extended survival with the use chemotherapy has been shown in many pancreatic cancer patients
including patients who have chemotherapy in addition to surgery or radiation for tumors
confined to the pancreas, patients using chemotherapy for primary treatment of inoperable
tumors which are confined to the pancreas, and for patients using chemotherapy for treatment of
metastatic pancreatic tumors. The most common type of chemotherapy to be used for pancreatic
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cancer is Gemzar; the generic name is gemcitabine, this drug was approved to be the standard of
care for pancreatic caner in 1996. Fluorouracil was the standard chemotherapy used prior to
gemcitabine. Gemzar is typically used after a patient has had surgery for tumors, which were
confined to the pancreas. Used in combination with other chemotherapy drugs Gemzar can be
used to control the metastasis of cancerous cells and improve survival. (12, 15)
Although chemotherapy has many positive effects on treating cancer it also has many
adverse effects due to the attack of rapidly dividing cells, including healthy cells. Healthy rapidly
dividing cells within the body include bone marrow, bloods cells, cells of hair follicles, and cells
of the reproductive and digestive tract. Side effects generally depend on the type of
chemotherapy, the dose, and length of treatment. Common side effects include fatigue, hair loss,
low blood cell count, gastrointestinal discomfort, diarrhea, abdominal cramping, nausea,
vomiting, neuropathy, as well as loss of appetite and change of taste. (12, 15)
Targeted Therapy
In addition to surgery and chemotherapy, targeted therapy is an additional option.
Tarceva, generic name erlotinib, was FDA approved in 2005. Tarceva used in combination with
chemotherapy drug Gemzar is used in locally advanced and metastatic pancreatic cancer, which
cannot be removed surgically. Targeted therapy works in two ways, both of which cause little to
no harm to healthy cells. The first way targeted therapy works is by stopping abnormal growth
behavior of a tumor by blocking the process that changes normal cells into cancer. The second
way targeted therapy works is by preventing the formation of blood vessels that bring nutrients
to the tumor. Specifically Tarceva targets Human Epidermal Growth Factor Receptor 1, which is
found in abnormally high levels on the surface of some pancreatic cancer cells. By targeting this
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growth factor, Tarceva blocks the growth of the cancerous cells. The side effects of this target
therapy include fatigue, rash, nausea, loss of appetitive, and diarrhea. (15)
Radiation
Radiation treatment is the last treatment option for pancreatic cancer aside from
symptomatic treatment. Radiation can be used in combination with surgery and chemotherapy,
however when radiation is given along with chemotherapy the chemotherapy is at a lower dose
than when it is administered alone. Chemotherapy acts as a radiosensitizer, which enhances the
effects of the radiation on the tumor. Unlike chemotherapy radiation cannot kill cancer cells,
which have spread, radiation is considered a local treatment. Radiation therapy uses high-energy
waves to kill cancer cells or prevent them from dividing, prevent tumors from growing, and
sometimes shrinks the tumor. There are two main types of radiation therapy including external
beam radiation and internal radiation also known as brachytherapy. External beam radiation, as
its name indicates, is delivered by a linear accelerator located outside of the body, which focuses
x-rays directly on the tumor. Internal radiation, rarely used in pancreatic caner, involves the
implantation of small amounts of radioactive materials in or near the caner.
Radiation does have some adverse side effects associated with it. Patients may experience
some abdominal discomfort towards the end of treatments, however the treatments are not
painful. Overtime however, the effects of radiation can build up. Common side effects include
loss of appetite, nausea, diarrhea, and fatigue. Side effects typically peak from four to five weeks
after the first radiation treatment and resolve one to two weeks after completed treatment. (4, 12,
15)
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Symptomatic Treatment
Surgery, chemotherapy, targeted therapy, and radiation therapy all can help by varying
degrees the treatment of pancreatic cancer. However, as pancreatic cancer does progress it can
affect multiple organs causing multiple side effects such as pain, nausea, and jaundice. Side
effects from surgery, chemotherapy, targeted therapy and radiation can cause decreased ability of
digestion, nausea, vomiting, and fatigue. Pain management is important throughout the process
of treating pancreatic cancer. Pain, which radiates from the abdomen to the back, occurs when
the pancreatic cancer cells invade the celiac plexus, a cluster of nerves in the lower abdomen
from which sensory nerves in the pancreas, gallbladder, biliary tract, and other nearby organs
grow. Pain management using opioid analgesics, such as morphine can effectively relieve pain in
most patients. (12)
As mentioned previously pancreatic tumors can block the bile duct causing a buildup of
bilirubin in the liver leading to jaundice and itching. For relief from jaundice a stent can be
placed into the bile duct relieving the blockage. This treatment can relieve the patient from
discomfort and improve the patient’s quality of life. (12)
Rehabilitation services may be necessary for patients following treatments and surgery in
order to help build strength, flexibility, balance, and endurance. Treatments for depression may
also be necessary as well as supportive measures throughout the treatment. (12)
Treatments that help decrease the progression or eliminate pancreatic cancer can interfere
with the production of digestive enzymes and insulin. Patients typically require medications and
enzymes to aid in digestion and maintain blood sugar levels. Nutrition is essential in these
patients. (10, 12) Many of the medications patients take are for the nutrition implications that
occur. Pancreatic enzymes including pancrelipase and pancreatin are commonly taken. Enteric
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coating of the enzyme aids in maintaining the integrity of the enzyme until it reaches the small
intestine. As much as 20,000-30,000 units of lipase may be needed per meal and 10,000 units
may be needed with snacks. In addition insulin may be needed if the patient is hyperglycemic,
however with islet cell tumors hypoglycemia may occur, it is important to monitor glucose at
meals. Acid reducing medications such as proton pump inhibitors or H2 blockers are typically
needed. Water-miscible fat-soluble vitamins A, D, E, and K, such as Vitamax, Source CF, and
ADEKs, will be needed until intake of pancreatic enzymes is sufficient. Appetite stimulants such
as Megace may be appropriate if the patient’s intake is declining. Antiemetics and diuretics may
be needed. If the patient has loose stool Calcium Carbonate twice daily may be useful. Imodium
and Lomotil are antidiarrheal medications, which may be useful if loose stools are persistent.
Pain medications are often needed to treat pain associated with pancreatic cancer. Often opioids
such as codeine, hydrocodone, hydromorphone, oxycodone, and morphine are needed for the
treatment of pain, however acetaminophen and NSAIDs, such as aspirin and ibuprofen are also
commonly used as well. (9) For nutrition implications of these medications refer to the
Medication Bibliography on page 42.
Labs to Review for Pancreatic Cancer
It is necessary to monitor lab values especially glucose, amylase, lipase, bilirubin,
aspartate aminotransferase and alanine aminotransferase, prealbumin, C-reactive protein, fat
soluble vitamins, as well as sodium, potassium, chloride, phosphorus, magnesium, and calcium.
If a patient is receiving chemotherapy monitoring WBC and platelet count is also important. (9,
14)
Monitoring blood glucose levels is necessary to determine if the patient is having
problems producing insulin or glucagon causing either hyper or hypoglycemia. In these cases a
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patient may require insulin or Diazoxide, a drug which blocks insulin release from the pancreas
to prevent hypoglycemia. (9, 14)
Amylase and lipase levels may increase if there is an obstruction of the pancreatic duct
causing an outpouring of amylase into the intrapancreatic lymph system and free peritoneum.
Blood vessels drain the free peritoneum and absorb the lymph picking up excess amylase. Lipase
levels are less useful in chronic pancreatic diseases such as pancreatic carcinoma. (9,14)
Bilirubin is another lab value that is important to monitor. Bilirubin metabolism begins
with the breakdown of red blood cells; hemoglobin is released from red blood cells and broken
down to heme and globin molecules. Heme is then catabolized to form biliverdin, which is
transformed into bilirubin, also known as indirect bilirubin. In the liver, indirect bilirubin is
conjugated forming conjugated or direct bilirubin. The conjugated bilirubin is then excreted from
the liver and eventually into the common bile duct. High levels of conjugated bilirubin may
indicate extrahepatic duct obstruction or among other possibilities extensive liver metastasis.
(9,14)
An increase in alanine aminotransferase, also known as ALT, levels may indicate injury
or disease affecting the liver parenchyma causing a release of this hepatocellular enzyme into the
blood stream. In general most ALT elevations are caused by liver disease. When disease or
injury affects the cells of the liver tissue, the cells lyse. The aspartate aminotransferase, also
known as AST, is released and picked up by the blood causing the serum levels to rise. The
amount of AST elevation is directly related to the number of cells affected by the disease or
injury. Increased levels may indicate hepatic metastasis. (9,14)
Prealbumin is one of the major plasma proteins and can be used to determine protein
status, however prealbumin is significantly reduced in hepatobiliary disease because of impaired
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synthesis. Serum levels of prealbumin can decrease with inflammation, infection, malignancy,
malnutrition, and with zinc deficiency. To help determine the degree of inflammation occurring
in the body C-reactive protein, CRP, is a nonspecific, acute-phase reactant used to diagnosis
infectious disease, and inflammatory disorders. The liver primarily produces CRP during an
acute inflammatory process and other diseases. (9, 14)
Monitoring fat-soluble vitamins is necessary to indicate if the patient is able to absorb
fats. Lastly monitoring electrolytes, such as sodium, potassium, chloride, phosphorus,
magnesium, and calcium is also important for monitoring hydration status and acid base balance.
(9,14)
When a patient is undergoing chemotherapy the patient’s white blood cell count can
become very low due to the failure of the bone marrow to produce more cells. During times that
white blood cells are low the patient is considered to be under neutropenic precautions meaning
the patient is very vulnerable to infection and cannot effectively fight infections. The platelet
count may also be low during this time. Platelets are essential for blood clotting; platelet count
can be used to monitor the course of a disease such as thrombocytopenia or bone marrow failure.
(9, 14)
Palliative Care and Hospice
When the patient is looking for symptomatic relief rather than a cure palliative care is an
option. The focus of palliative care is to prevent, treat, reduce, or remove discomfort. Length of
life and quality of life are equally important when talking about palliative care. Palliative care
respects the cycle of life and recognizes death as a natural end of life cycle.
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Hospice is appropriate for patients wanting high quality end of life during the last
months, day, and hours of life. Life expectancy for these patients is generally no longer than six
months. Hospice focuses on relieving symptoms and increasing comfort. (15)
Medical Nutrition Therapy
An interdisciplinary approach to the treatment of pancreatic cancer is necessary for
optimal outcomes; once pancreatic cancer is diagnosed there are many nutritional implications
that can compromise the patient’s outcome. The advice of a registered dietitian can help prevent
nutritional deficiencies, preserve lean body mass, reduce and control nausea and vomiting,
control side effects of therapies, manage pancreatic cancer related diabetes, manage nutrition
support and weaning of nutrition support, and maximize the patients quality of life. (9) When
pancreatic cancer is present, many conditions that affect nutritional status occur including
malabsorption, anorexia, early satiety, abdominal pain, and constipation from medications, and
pancreatic fistula, to name a few. Physical observations of a patient may reveal the presence of
dehydration and cachexia, which typically occurs with advanced stages. All of the factors
previously mentioned are necessary to consider when assessing the patient and choosing the
most appropriate nutrition. (9, 15, 16)
Nutrition Implications of Cancer
Cancer is a catabolic disease and process. Cancer cachexia is very common among cancer
patients; this wasting syndrome is characterized by weight loss, anorexia, early satiety,
progressive debilitation, and malnutrition. Tumor factors such as proteolysis-inducing factor,
tumor necrosis factor, and lipid mobilizing factor all promote catabolism. High protein turnover
and loss of nitrogen, significant loss of muscle mass, and impaired physical capacity are common
in malnourished cancer patients. A loss of lean body mass due to mobilization of protein stores is
20
common, as well as altered nutrient utilization causing glucose intolerance, insulin resistance,
increased glucose turnover, lipolysis, hyperlipidemia, and increased protein turnover. Cachexia is
typically characterized by a disproportionate loss of muscle mass, involuntary weight loss greater
than 5% within 6 months, typically low serum albumin, and increase serum C-reactive protein.
(9)
Nutrition status of patients with cancer can vary. When beginning cancer therapy patients
with anorexia, weight loss, and other symptoms of nutritional problems may complicate the
treatments and expected recovery. In addition some patients may have preexisting comorbid
diseases that may further complicate treatment. Cancer patients that best tolerate treatments and
have better recovery are those who typically have had early interventions to side effects,
maintained their weight, and maintained nutritional stores. (4) Many cancer patients experience a
decrease in food and beverage intake, which many times are due to a decrease in appetite, change
in small and taste, nausea, vomiting, diarrhea, and lethargy. It is important for cancer patients to
maintain a well balanced diet, providing them with adequate calories, proteins, fluids, vitamins
and minerals. (4, 9)
Nutrition Assessment
The nutrition assessment of a patient includes an evaluation of calorie, protein, and fluid
needs, as well as an evaluation for the need of pancreatic enzymes, acknowledging anorexia, and
among other nutritional assessments evaluating for malnutrition. When calculating patient’s
nutritional needs it is important to consider an individual’s diagnosis, comorbidities, anticancer
therapies, and the presence of fever, infection. Nutrition requirements for cancer patients are
determined based on the individual patient as well as cancer-specific requirements. Many
patients have typical needs of 25-30kcal/kg to maintain their body weight. However, some
21
patients have an increase resting energy expenditure, which increases their nutritional needs.
Energy needs can typically be calculated at 30kcal/kg of body weight for maintaining weight or
at 35-45kcal/kg of body weight if a patient has lost weight, is febrile, septic, or very active. Other
equations are available to calculate energy needs; using indirect calorimetry is ideal to determine
energy needs. (3, 9)
Protein needs may be higher for cancer patients, to maintain body weight 1.0 – 1.5gm/kg
is needed where as for repletion of lean body mass 1.5 – 2.0gm/kg would be appropriate to
protect against muscle wasting, malnutrition, cachexia, and losses from treatments. When
assessing protein needs it is important to take into consideration if the patient’s body is under
stress, experiencing malnutrition, and the extent of the cancer. Protein needs are generally
increased when the body is under stress due to its many important functions, including
maintaining a healthy immune system and repairing tissues. (3, 9)
Appropriate fluid intake to avoid dehydration is also important; consuming 1ml/kcal is
typically appropriate. When calculating fluid requirements, it is important to ensure the patient is
maintaining hydration and electrolyte balance. It is also necessary to take into consideration
fever, ascites, edema, vomiting, diarrhea, IV fluids, impaired renal function, and medications
when determining fluid needs. (6, 9)
It is important to monitor for weight loss; weight loss can contribute to fatigue, delay in
the length of recovery, and adversely affect quality of life. Reevaluation of patient’s nutritional
needs is necessary to ensure the appropriate amounts of calories, proteins, and fluids are being
provided. (6, 9)
Pancreatic insufficiency is common when diagnosed with pancreatic cancer, when this
occurs the pancreas is unable to secrete enzymes needed for digestion. Typically the Whipple
22
procedure, total pancreatectomy, blockage or narrowing of the pancreatic or biliary duct, or
pancreatic or duodenal tumors can specifically cause the need for pancreatic enzymes. Patients
should consider initiation of pancreatic enzymes when they have feelings of indigestion,
cramping after meals, large amounts of gas, foul smelling gas or stools, floating or fatty stools,
frequent stools, loose stools, and weight loss. In addition to taking the pancreatic enzymes for
pancreatic insufficiency medium chain triglycerides, fat-soluble vitamins, and essential fatty
acids should also be included to prevent deficiencies due to possible malabsorption of fats.
According to the Academy of Nutrition and Dietetics supplementation of Omega-3 fatty acids
has not been shown to have anticachetic effects leading to changes in body composition and is
not recommended for patients with pancreatic caner. Eicosapentaenoic acid also was not
associated with an increase in lean body mass. In addition the use of eicosapentaenoic acid after
12 weeks of supplementation did not show a decrease in C-reactive protein. (9, 15, 16, 17)
Malnutrition and Cancer
Anorexia can become a serious problem and progress to cause malnutrition for patients
with pancreatic cancer. Although a lack of appetite can be increased through medications it may
first be appropriate to try adding nutritional supplements in between meals, increase the calorie
contents of foods, and eat small frequent meals throughout the day. The etiology of the anorexia
is important when providing recommendations. Abdominal and back pains caused by pancreatic
cancer may also cause the patient to have anorexia, the use of pain medications in this scenario
may help decrease the patient’s anorexia. In addition to anorexia, delayed gastric emptying may
become a concern for the patient, which would cause early satiety. It is important to avoid simple
sugars when having delayed gastric emptying and consuming about six to eight small meals per
day. (9, 15)
23
Malnutrition is a common problem that may arise for many reasons with pancreatic
cancer patients. One indicator for malnutrition is BMI, a BMI of 18.5kg/m2 or less indicates a
patient is underweight. However, BMI is not the only indicator for malnutrition and individuals
with a healthy BMI or are considered overweight and obese may be malnourished. Many
laboratory tests also can help indicate malnutrition, such as low levels of albumin, prealbumin,
total protein, C-reactive protein, transferrin saturation, lymphocytes, and electrolytes. In addition
the Subjective Global Assessment, SGA, is a tool that is found to be predictive of nutrition
associated complications. The SGA identifies malnutrition, distinguishes malnutrition from a
disease state, predicts outcomes, and identifies patients in whom nutritional therapy can alter
outcomes. Malnutrition may also be identified when a patient is losing weight or has an
alteration in gastrointestinal symptoms, such as vomiting and diarrhea. Malnutrition requires an
increase in a patients calories and protein needs. (9)
Surgery and Nutrition
As discussed previously there are several surgical options for pancreatic cancer patients.
Including the Whipple procedure, pylorus preserving Whipple procedure, distal pancreatectomy,
and a total pancreatectomy. All of these surgeries cause an alteration of the gastrointestinal tract
and initially require additional nutrition recommendations. Following surgery, one complication
that can occur is the formation of a pancreatic fistula, when this occurs there may be leakage of
pancreatic secretions from disrupted pancreatic ducts from the site of the resection. Pancreatic
fistulas can lead to morbidity due to malnutrition and infection. The majority of patients with
pancreatic fistulas can be managed with either maintenance of an oral diet or parenteral nutrition
until closure of the fistula depending on the patient’s condition. (18,19,20)
24
Following the Whipple procedure the most common complication is delayed gastric
emptying, which typically resolves in 7-10days but could last a few weeks. If the patient is not
receiving adequate nutrition, enteral nutrition support may be considered. The patient may also
experience digestive difficulties, requiring the use of pancreatic enzymes. Initially the patient
will only eat small amounts of easily digestible foods. Parenteral nutrition is not necessarily
required following this procedure and many patients show better outcomes from standard
nutrition. Diarrhea is also a common problem for the fist few months after the procedure. Most
patients will experience weight loss, however to avoid malnutrition it may be necessary to
consume supplements between meals. Diabetes may also develop depending on how much of the
pancreas was removed and how many insulin producing cells were removed. The same
complications occur following the pylorus preserving Whipple procedure, however some studies
have shown increased delayed gastric empty following the pylorus preserving procedure. (15,18,
21,22)
The distal pancreatectomy has minimal nutrition complications compared to the other
procedures. However the total pancreatectomy has the most nutritional implication following the
procedure. The patient will have diabetes and require insulin injections following the procedure
due to the entire pancreas being removed, in addition the patient will lack pancreatic digestive
juices and with everything consumed will need to take pancreatic enzymes for proper digestion
of food. With total pancreatectomy vitamin B12 supplementation may be required, particularly
with steatorrhea. (15)
Postoperative feeding can be done through enteral feeds supplemented with fiber and a
combination of prebiotics and probiotics administered through a jejunostomy. This may reduce
infections and antibiotic use. If enteral nutrition is not possible, parenteral nutrition should be
25
initiated in critically ill patients who are malnourished with a weight loss of more than 10% prior
to admission or if the patient is less than 90% of their ideal body weight. If enteral nutrition is
not possible, parental nutrition is to be used, the parenteral nutrition should be provided for five
to seven days preoperatively and continued into the postoperative period. Only initiate parenteral
nutrition if support is to be provided for seven or more days. (16)
Chemotherapy, Targeted Therapy, and Radiation: Nutrition Implications
Chemotherapy, as previously discussed, kills rapidly dividing cells, which can cause
many nutritional complications. Some nutrition related side effect include anemia, neutropenia,
electrolyte imbalance, constipation, diarrhea, malabsorption, dysphagia, stomatitis, mucositis,
dehydration, nausea, vomiting, anorexia, dysgeusia, fatigue, weight loss, and pain. Management
of these side effects can help improve outcomes and improve the patient’s quality of life. When
these side effects of chemotherapy are present, the patient may become malnourished and decline
in overall health if not appropriately handled. There are many techniques to help resolve these
side effects. As with chemotherapy, targeted therapy has similar but less, nutritional side effects.
The side effects include fatigue, loss of appetite, nausea, and diarrhea. As with many drugs the
severity of the side effects depends on the dose of the drug and the duration of its use. (9, 15, 16,
23)
Radiation therapy’s effects can build up over time with additional treatments. The side
effects include loss of appetite, nausea, diarrhea, and fatigue. The side effects typically peak at
four to five weeks after the initial treatment and resolve within one to two weeks after the
treatment is complete. Skin redness may occur as well as “burning” of the skin and within the
abdomen, this may occurs after multiple treatments, however it is less likely in pancreatic cancer
26
patients. If burning occurs, the patient may have discomfort during meals and therefore have a
decreased intake. (9, 15, 16, 23)
When a patient is being treated with chemotherapy, targeted therapy, and radiation, it is
important to control side effects. If the side effects are not addressed, the patient may decline due
to their interrelationship. For example if a patient is experiencing vomiting and diarrhea the
patient may subsequently become dehydrated, malnourished, and experience weight loss.
Oral Intake and Aggressive Feeding
Oral feeding is the optimal feeding technique unless contraindicated. The patient should
feed orally if possible. If the patient’s intake decreases it is necessary to determine the cause of
the decreased intake. Individuals experiencing early satiety, anorexia, and alteration in taste,
xerostomia, mucositis, nausea, diarrhea, fatigue, or depression may require eating foods high in
energy, protein, and micronutrients to help maintain nutritional status. (4,9,21)
Poor appetite or loss of appetite is a common problem with cancer patients, the cause
being multifactorial. Cancer itself, cancer treatment, and psychosocial factors may all effect
appetite. Consuming frequent high calorie meals and snacks that are easy to prepare may be
helpful in addition to eating in a clam and comfortable environment. Planning a daily menu in
advance, arranging for help in preparing meals, and adding extra protein and calories to foods is
also helpful. (4,13,23)
Alternations in smell and taste are related to unknown effects of cancer, treatments,
mucositis, thrush, or medications. Change in taste, or dysgeusia, can result in food avoidance,
including weight loss and anorexia. Changing the types of foods eaten as well as adding
additional spices may help improve the taste of food. Rinsing the mouth prior to eating may help
improve the taste of foods. If the taste of metal is bothersome using plastic utensils may be
27
helpful. It may also be helpful to have someone else prepare meals to avoid strong scents. In
addition if food aroma is a problem consuming cold foods may be helpful. (4, 9, 23)
Xerostomia is a condition of dry mouth and commonly is caused by radiation especially
to the head and neck area. Dry mouth may affect taste sensation and ability to swallow. Drinking
plenty of liquids and eating moist foods with extra sauces, gravies, butter, or margarine is
helpful. Hard candies, frozen desserts, and ice chips can also help. Consuming very sweet or tart
foods and beverages may help stimulate saliva. (4, 9, 23)
Sore mouth is caused when rapidly dividing cells inside the mouth are damaged by
treatments such as chemotherapy and radiation therapy. Patients may be more susceptible to
infection and bleeding in their mouth. It may be easier to eat when carefully choosing foods and
taking good care of their mouths. The best foods to choose are foods that are soft, easy to chew
and swallow, and nonirritating. Acidic, spicy, salty, and coarse-textured foods are considered
irritants. (4,9,23)
Nausea is a very common problem of all cancer patients. Eating before treatments is
important, as well as identifying foods that trigger nausea. Nausea is typically caused by spicy,
greasy, and strong odor foods. Frequent eating and slowly sipping fluids is helpful. In addition
eating bland, soft, and easily digestible foods may help in addition to sitting up or recline with a
raised head for one hour after eating. If nausea is persistent, nausea medication may help.
(4,9,23)
Diarrhea is caused by radiation, chemotherapy, gastrointestinal surgery, or emotional
distress. It is necessary to maintain hydration status and electrolyte balance when having diarrhea
to avoid hyponatremia, hypokalemia, and dehydration. Greasy foods, hot or cold liquids, and
caffeine may worsen diarrhea. Drinking one cup of liquid following each loose bowel movement
28
will help prevent dehydration. In addition consuming broth, soups, sports drinks, bananas, and
canned fruits may help replenish electrolytes. (4,9,23)
At times patient’s may find eating to be exhausting but should be encouraged to try
eating; resting before and after meals may help eating be less exhausting. Due to the poor
prognosis of pancreatic cancer, many patients may feel depressed and have little desire to eat.
Talking about feelings and fears may make emotions more manageable. (4,9,23)
Nutritional Supplements and Appetite Stimulants
When the patient is not hungry for solid foods, high calorie beverages and supplements
can always be consumed. Nutritional supplements such as Ensure, Boost, Carnation Instant
Breakfast, and Magic Cup can help increase calories and protein intake. These are especially
helpful for patients who do not have an appetite or who cannot consume enough calories in a
day. (3, 9)
Appetite stimulants are appropriate for patients with no appetite and who have nausea
and vomiting under control. Appetite stimulants include medications such as Dronabinol,
Megestrol Acetate, and Anabolic Steroids such as, Oxandrolone, Nandrolone, and Decanoate.
Dronabinol is a marijuana derivative, which takes on average four to six weeks to show effects;
patients may experience extreme tiredness and impaired memory when taking this drug.
Megestrol Acetate, also known as Megace, is useful for stimulating appetite. The dose of
Megace needed to stimulate appetite is typically 800mg/day. Anabolic steroids use for appetite
stimulation, known as Oxandrin, is a synthetic testosterone that promotes weight gain and
increased muscle mass. However, hepatic changes or tumors have been reported. Elevation of
low-density lipoprotein can occur with prolonged used causing possible cardiovascular effects.
(9, 24, 25)
29
Enteral and Parenteral Nutrition Support
When adequate oral intake is not possible, supplemental feeds may be initiated through
enteral nutrition. If the patient cannot feed orally and their gastrointestinal tract is functional
enteral feeds would be initiated at that time as well. When malnutrition is of concern, the patient
may require supplemental enteral nutrition feeding. Patients may require either short-term enteral
feedings or may require long-term enteral nutrition. Short-tern enteral nutrition would require a
nasogastric or a nasojejunal tube. Long-term enteral nutrition is indicated when enteral nutrition
is required for three to four weeks, a gastrostomy or jejunostomy feeding tube should place.
Contraindications
for
enteral
nutrition
include
malfunctioning
gastrointestinal
tract,
malabsorptive conditions, mechanical obstructions, severe bleeding, severe diarrhea, intractable
vomiting, gastrointestinal fistula in locations difficult to bypass with an enteral tube,
inflammatory bowel process, or overall prognosis not consistent with aggressive nutrition
support. Enteral nutrition generally has fewer complications than parenteral nutrition and helps
maintain the function of the gut. If enteral nutrition is indicated a formula is chosen based on the
patients nutritional needs, comorbid conditions, and energy and protein content needs among
other factors. (4,9)
However, if the patient does not have a functioning gastrointestinal tract, parenteral
nutrition can be initiated. Parenteral nutrition may also be required if the patient requires shortterm supplemental nutrition but is experiencing thrush, mucositis, or esophagitis and a temporary
tube cannot be replaced. Complications from parenteral nutrition can occur including fluid
overload, hyperglycemia, electrolyte imbalance, and infections. If parenteral nutrition is
indicated, either a central or peripheral intravenous line must be placed. Central lines can tolerate
30
a higher osmolality solution, allowing for more calories and protein to be administered at one
time. (4,9)
Nutrition support is generally indicated when treatment options are aggressive. When
patients are considering less aggressive treatments or are looking for comfort measure nutrition
support may not be initiated. However, for patients who start with aggressive treatments and
nutrition support, nutrition support may be maintained while receiving comfort care. (4)
Palliative Care and Hospice: Nutrition
When a patient and their family decide for palliative care or hospice the focus of nutrition
becomes comfort care. Palliative care will provide nutrition for the patient, however the focus is
on pleasure and not on providing enough nutrients for the patient. The goal of palliative care is to
treat and prevent symptoms, side effects, and psychological, social, and spiritual concerns caused
by the cancer or the treatment. However hospice care focuses on providing a high quality of life
during the last months of life. The nutrition and hydration of the patient is based on the patient
and caregivers wishes. (4,15)
Presentation of the Patient
October 5, 2012 DR was admitted to St. Mary’s Medical Center for nausea, vomiting,
abdominal pain and diarrhea. She is a 72 year old Caucasian female, who lives at home with her
husband and prepares the meals for her husband. DR’s past medical history includes transient
ischemic attack, angina, coronary stent, hypercholesterolemia, hypertension, deep venous
thrombosis in her right leg, gastroesophageal reflux disease, renal disease, urinary tract infection,
spinal stenosis, spinal fusion, and type 2 diabetes. DR was having nausea, vomiting, abdominal
pain, and diarrhea for several months prior to admission and had a thirty-pound weight loss. The
CAT scan done on admission revealed multiple liver metastases as well as a mass in the head of
31
the pancreas. Prior to admission the patient underwent an ERCP and biliary stent at Jefferson
University Hospital. The ERCP revealed Stage IV pancreatic cancer involving the liver and
pancreatic head with obstructive jaundice.
Hospital Course

October 4, 2012: The patient arrived at St. Mary’s Medical Center’s ER complaining of
nausea, vomiting, abdominal pain, and diarrhea. She also reports having a thirty-pound
weight loss in the past six months. A CAT scan was done and revealed diffuse lobular
pancreatic enlargement with diffuse infiltrative masses compatible with neoplasm,
presumably adenocarcinoma, which biopsy previously confirmed. Liver metastases and
ascites were also noted.

October 6, 2012: The patient is jaundiced but currently has no further nausea and
vomiting. The patient underwent an abdominal ultrasound revealing multiple
intrahepatic masses, the 8mm common bile duct stent is in position, and there is no
persistent or recurrent bilary ductal dilatation, additional small amounts of ascites are
noted. The patient currently taking Omeprazole, Lovenox, Zofran, Morphine,
Loperamide, and Sliding Scale Insulin.

October 8, 2012: A CT scan was done showing stable pancreatic mass with local porta
hepatis nodes. New pleural effusions, ascites, and anasarca are also noted.

October 10, 2012: At this time DR had an access port placed. During the day the patient
had significant abdominal pain, discomfort and nausea. At this time the patient’s
medications include Bacitracin, Lantus, Omeprazole, Lovenox, Zofran, Morphine,
Loperamide, Pancrelipase, and Novolog.

October 15, 2012: The patient received 250ml packed red blood cell transfusion.
32

October 16, 2012: DR continues to have nausea. The physician states the prognosis of
the patient is poor. Medications include Promethazine, Procrit, Zofran, Dilaudid,
Norvasc, Ativan, Lantus, Omeprazole, Pancrelipase, and Novolog.

October 17, 2012: The patient received 250ml packed red blood cell transfusion.

October 18, 2012: The patient received 125ml packed red blood cells and 256ml of
platelet cell transfusion.

October 21, 2012: The physician initiated total parenteral nutrition. DR had tenting of
the skin, decreased breathing, abdomen soft and distended with tenderness, as well as +1
pitting edema. The patient looks cachectic and has moderate discomfort. The patient’s
blood counts are improving after receiving chemotherapy, cycle 1, with Gemcitabine.
The physician plans to wait for the patient’s platelet count to increase over 75,000mcL
and may consider 5-FU- oxaliplatin. The physician plans to add insulin to the TPN as
well as taper down the TPN.

October 22, 2012: The physician states the patient has improving appetite and remains
on TPN, however plan to discontinue by half. The patient has extremity swelling causing
her difficulties to ambulate. The patient also has significant anasarca. The patient is
stating she wants to go home, however her husband feels he cannot take care of her. DR
does not want to go to a skilled nursing facility and wants to remain a full code. Today
patient’s husband toured Chandler Hall, an inpatient hospice center.

October 23, 2012: TPN is running at half strength.

October 24, 2012: The patient has a poor prognosis, and is status post one cycle of
chemotherapy, has hypoalbuminemia, and anasarca. The patient is discharged to hospice
with metastatic pancreatic cancer, +3 pitting edema, diffuse anasarca, malnutrition
33
requiring TPN, thrombocytopenia, anemia, neutropenia, hyperglycemia, hypoglycemia,
pancreatic insufficiency, liver failure with elevated bilirubin levels.
Patient’s Lab Values
Throughout the patient’s hospital course her lab work was monitored. For lab values refer
to table 3 in the appendix. Upon admission, the patient’s bilirubin, liver enzymes, and glucose
levels were elevated, in addition the patient’s albumin level was low. A few days following DR’s
admission, her CA 19-9 Antigen was at 52704units/mL, normal values are less than 34units/mL,
this antigen is a marker for pancreatic cancer. The patient’s glucose levels ranged from
378mg/dL to 42mg/dL throughout her hospital course; as DR’s hospital stay progressed her
glucose levels remained high until her last glucose level, which was very low. The patient’s
bilirubin levels decreased but were still elevated, the decrease may have been due to the stent the
patient had placed prior to admission. The patients liver enzymes remained elevated and
increased throughout her stay, which may have been due to the metastasis of the cancer to her
liver. DR’s albumin levels remained low throughout her stay and the only prealbumin value was
also very low at 4.0mg/dL. Lastly DR’s platelet count and white blood cells decreased
throughout her stay, this was possibly due to her chemotherapy treatments.
Nutrition Course of the Patient
Assessment: On October 5th, DR was experiencing nausea and vomiting and had lost 30
pounds in six months. DR’s weight loss of 23% in six months is considered significant. When
speaking with the patient she states she has had nausea, vomiting, diarrhea, and a decrease in
appetite for several months and has been experiencing some pain. DR’s weight at the time of
visit was 47kg, height of 157cm, and BMI of 19kg/m2. Due to DR’s low BMI, recent weight
loss, and recent nausea, vomiting, and diarrhea, her energy and protein needs were estimated at
34
30-35kcal/kg and 1.2-1.3gm of protein/kg; DR’s needs were calculated to be 1410-1645kcal and
56-61gm of protein. Diagnosis: Inadequate oral intake related to metastatic pancreatic cancer as
evidenced by a significant weight loss of 23% in 6 months. Intervention: Recommend a regular
diet with Ensure Plus twice a day and consuming at least 75% of meals. Recommend weighing
patient two times per week. Monitor and Evaluate: Monitor meal intake percentages and
patient’s intake of Ensure Plus twice daily. Additionally monitor DR’s weight.
Assessment: On October 8th, DR’s appetite had not improved since October 5th. Her
meal intakes were fair, consuming about 25-50% of meals. DR is expected to start chemotherapy
soon. Her needs were kept the same as her initial assessment. Diagnosis: Inadequate oral intake
related to patient with no appetite as evidence by patient consuming 25-50% of meals.
Intervention: Encouraged patient to try consuming small frequent meals, recommended to
continue drinking Ensure Plus twice daily, and continue with the anti-nausea medication.
Recommend weighing patient 2x per week. Megace was recommended if DR’s intake did not
improve. Monitor and Evaluate: Monitor tolerance to diet, monitor blood glucose levels. Monitor
weights two times per week. The patient was followed up with again on October 11th with no
significant changes noted.
Assessment: On October 15th, DR stated she was ordering small amounts of food, and
having intermittent nausea and vomiting. The patient received chemotherapy on October 10th.
DR is now taking pancreatic enzymes. High calorie supplements were discussed with the patient,
who expressed her concern about not consuming enough solid foods and was also concerned
about controlling her nausea. Diagnosis: Inadequate oral intake related to chemotherapy and
pancreatic cancer as evidence by poor meal intakes, weight loss, and intermittent nausea.
Intervention: Encourage small frequent meals and consumption of Ensure Plus twice a day,
35
weigh twice a week, control nausea with medications. Monitor and Evaluate: Monitor patient’s
intake and the need for an appetite stimulant, as well as recommend small frequent meals, and
control of nausea.
Assessment: At DR’s next follow up on October 18th, it was noted the physician initiated
TPN. Through a central line, the patient was receiving a TPN solution containing 70%
carbohydrates, 30% lipids, and 1.2gm of protein/kg. DR’s oral intake decreased to poor intake,
consuming less than 25% of meals. At this time DR’s albumin was 1.1gm/dL and glucose of
169mg/dL. DR at the time of the visit had inadequate meal intakes, had initiated TPN, and
decreased serum protein. DR was experiencing excessive fluid overload, edema, and elevated
blood glucose levels. Recommended to consider a nasojejunal tube for nutrition support rather
than TPN. Diagnosis: Inadequate oral intake related to patient has nausea, vomiting, and no
appetite as evidence by patient consuming less than 25% of meals and initiated on TPN.
Intervention: Continue to encourage small frequent meals, continue consume Ensure Plus twice
daily, and weigh patient 2x per week. Monitor and Evaluate: Monitor patient’s weight and
continue to monitor meal intakes. Monitor tolerance to TPN, may want to consider discontinuing
TPN and initiating nasojejunal feeds.
October 22nd was DR’s final follow up assessment. Assessment: DR was still consuming
only fair intake, albumin of 1.2mg/dL and prealbumin of 4mg/dL. The patient was still receiving
TPN at this time. She expressed concern that she was not receiving enough oral nutrition. The
physician at this time is noting the patient to have a poor prognosis and plans to wean DR from
TPN. The TPN is contributing to fluid retention and weight gain. The patient is currently
receiving Lasix and Aldactone. The patient and patient’s family are thinking of hospice.
Diagnosis: Inadequate oral intake, related to poor appetite, nausea, and vomiting, as evidence by
36
patient consuming less than 25% of meals. Interventions: Recommend discontinuing TPN and
providing a regular house diet. Monitor and Evaluation: Will monitor meal intakes, watch for
weaning of TPN, and will monitor for the plan of care.
Critical Comments
After researching the topic of pancreatic cancer and learning all of the nutritional
implications, there are several things I would change about her nutritional care. It would have
been beneficial to speak with the nurses and physicians at further lengths to discuss the patient’s
nutrition and plan of care. Making sure the patient was receiving Zofran as needed, as well as
explain different techniques to the patient regarding reducing nausea. Additionally ensuring the
patient was receiving the pancreatic enzymes at the appropriate time may have helped the patient
with digestion of food. Talking with the attending physician may have prevented the initiation of
TPN, which was not appropriate for this patient. Speaking with the physician at further lengths
may have encouraged the use of a tube feeding for supplemental feedings, which may have
improved outcome or quality of life. A multidisciplinary care approach as well as acting as a
patient advocate could have contributed to an optimal outcome.
Monitoring DR’s labs more closely may have been beneficial, the patient’s albumin and
prealbumin remained very low, and liver enzymes increased over her time of stay. Additionally
checking the C-reactive protein and transferrin saturation may have provided additional
information on the patient’s nutritional status. Although DR was not consuming sufficient
nutrition, regardless it may have been more appropriate when calculating the patients needs to
adjust the patient’s body weight for ascites, which the patient presented with on admission.
Additionally I would have reassessed the patient’s needs and would have recommended
additional nutritional supplements and oral intake before initiating TPN. After the initiation of
37
TPN the patients triglycerides were elevated, glucose was high, as well as increased liver
enzymes. The patient also had fluid overload while on TPN. When TPN was initiated and
throughout the time she was receiving TPN, DR’s white blood cells were low, which increased
her risk of infection with TPN. Expressing these concerns with the physician would have been
appropriate.
After researching pancreatic cancer, it is necessary to consider that the patient had Stage
IV pancreatic cancer. This cancer was unresectable, and chemotherapy was her only option.
Comfort measures were possibly all that could have been done in this case. Helping the patient
overcome pain, nausea, vomiting and diarrhea through comfort measures may have improved
DR’s meal intake as well as improve her quality of life.
Summary
Many nutrition implications of pancreatic cancer can arise depending on the type of
pancreatic cancer, stage of cancer, and the treatments that may be provided. An individualized
plan of care is needed for patients because no two patients are the same. The nutritional status of
an individual throughout their course of treatment is important for recovery and quality of life. It
is necessary to also inquire as to why a patient is having nutritional problems and find ways to
help the patient achieve a solution. Always remembering to have a multidisciplinary approach
and patient centered care is key for optimal outcomes.
38
Glossary of Pertinent Medical Terms
Antigen: Antigens cause the immune system to make antibodies against the antigen.
Carcinoma in situ: A group of abnormal cells that remain in the place where they first formed.
They have not spread. These abnormal cells may become cancerous and spread into nearby
normal tissue. Also called stage 0 disease.
Computed Tomography Scan: Also known as a CT scan. This is a technique that combines a
series of x-rays to create cross-sectional images of the bones and soft tissues within the body.
C-Reactive Protein: Abbreviated CRP is a protein produced by the liver and found in the blood.
CRP increases after an injury, infection, or inflammation and decreases when the injury heals or
infection or inflammation clears.
DNA: Deoxyribonucleic acid is the heredity material within cells; DNA provides the instructions
for development and function of cells.
Eicosapentaenoic Acid: Abbreviated EPA, a type of Omega-3 fatty acid with 20 carbon atoms,
commonly found in fish.
Endoscopic Retrograde Cholangiopancreatography: Also known as an ERCP, this test
combines the use of an endoscope with an x-ray to examine the tubes that drain the liver,
gallbladder, and pancreas.
Endoscopic Ultrasound: Also known as EUS, this procedure combines an endoscopy and an
ultrasound to obtain images of the digestive tract and surrounding organs.
Eosinophils: Type of white blood cell produced in the bone marrow and migrates to tissues.
Different types of white blood cells release substances when foreign substances enter the body;
39
the substances released from the other white blood cells attract eosinophils, which release toxic
substances to kill invading substances.
Esophageal Varices: These are abnormally enlarged and extremely dilated veins in the lower
esophagus.
Fistula: An abnormal or surgically made passage between a hollow organ and the body surface,
or between two hollow organs.
Fluorouracil: Also known as 5-FU, is an antimetabolite used as an Antineoplastic agent.
Gastric Varices: These are abnormally enlarged and extremely dilated veins in the stomach,
typically in the fundus and cardia, which are located at the top portion of the stomach below the
esophagus.
Laparotomy: A laparotomy is a procedure to explore the organs within the abdomen. A surgical
incision is made into the abdomen wall.
Magnetic Resonance Cholangiopancreatography: Also known as a MRCP, this is an imaging
technique using magnetic resonance imaging to visualize the biliary and pancreatic ducts.
Magnetic Resonance Imaging: Also known as an MRI, this test using a magnetic field and
pulses of radio wave energy to produce pictures of organs and structures inside the body.
Mucin: This is a glycoprotein component of mucus.
Non-Steroidal Anti-Inflammatory Drugs: Abbreviated NSAIDs, these are medicines that
relieve pain, swelling, stiffness, and inflammation.
Oxaliplatin: An Antineoplastic agent used to treat metastatic carcinoma with 5-FU.
40
Portal Vein: This is a large vein that brings blood from the digestive organs, spleen, pancreas,
and gallbladder to the liver.
Pylorus: This is the lower part of the stomach that connects the stomach to the duodenum.
Splenomegaly: Is an enlargement of the spleen, an organ, which is involved in the production
and removal of blood cells, also forming part of the immune system.
Tumor Necrosis Factor: Abbreviated TNF, is a proinflammatory cytokine that is produced by
white blood cells; has an antineoplastic effect; one of multiple proteins capable of inducing
necrosis of tumor cells that possess a wide range of proinflammatory actions.
Xerostomia: Abnormal dryness of the mouth resulting from decreased secretion of saliva.
41
Medication Bibliography
Medications
Aldactone
(Spironolactone)
Indication
Ascites from cirrhosis
Contraindication
Anuria. Caution with
renal impairment,
hyponatremia, diabetes
mellitus, and elderly
patients.
Ativan
(Lorazepam)
Anxiety with depression
Caution with respiratory
impairment, central
nervous system
depression, seizure
history, renal
impairment, hepatic
impairment, and elderly
patients.
Creon
(Pancrelipase)
Exocrine pancreatic
secretion deficiency
(Pancreatic Cancer)
Caution if
hyperuricemia, renal
impairment, recurrent
GI obstruction history,
short bowel syndrome
history, and Crohn’s
disease.
Dilaudid
(Hydromorphone)
Moderate to Severe Pain
Respiratory depression,
asthma, and GI
obstruction. Caution
with elderly, renal
impairment, hepatic
impairment, and
pulmonary impairment.
Food-Drug Interaction
Take with meals or milk
to decrease GI irritation
and increase absorption.
Avoid natural licorice.
May cause dry mouth,
nausea, vomiting,
gastritis, cramps, and
diarrhea.
May take with food if
GI distress occurs. Limit
caffeine to <400500mg/day. Anorexia,
decrease in weight,
increased appetite
increased thirst, dry
mouth, nausea,
vomiting, constipation,
and diarrhea may occur.
Must take with food.
Take with meal or snack
and fluid. Follow by
glass of water or juice.
Insure adequate
hydration/fluid intake.
Nausea, vomiting,
stomach cramps,
bloating, constipation,
diarrhea, and flatulence
may occur.
Take with food. Increase
fluid and fiber to
prevent constipation.
Anorexia, decrease in
weight, dehydration, dry
mouth, taste change,
dysphagia, dyspepsia,
decrease gastric
mobility, nausea,
vomiting, constipation,
and diarrhea may occur.
Avoid Alcohol.
42
Gemzar
(Gemcitabine)
Pancreatic Cancer
Lantus
(Insulin Glargine)
Type 2 Diabetes
Lovenox
(Enoxaparin)
Prevention and
treatment of deep
venous thrombosis
Norvasc
(Amlodipine)
Hypertension and
Angina
Novolog
(Insulin Aspart)
Type 2 Diabetes
Phenergan
(Promethazine)
Nausea and Vomiting
Priolsec
(Omeprazole)
Gastroesophageal
Reflux
Caution with renal
impairment, hepatic
impairment, and
myelosuppression.
Decreases bowel
movement, may cause
nausea, vomiting, and
diarrhea, may cause
fever. May cause
stomatitis.
Hypoglycemia, Caution
Long Acting, Onset 1with infection, illness, or 2hrs, Duration 12-18hrs.
stress, hypokalemia,
No peak time, should
renal impairment, and
never be mixed with
hepatic impairment.
another insulin in the
same syringe.
Hypersensitive to pork
Do not take with pork
products. Caution if
allergy: derived from
bleeding risk, recent
porcine intestinal
surgery or trauma,
mucosa.
diabetic retinopathy, and
coagulation disorder.
Caution with severe
Grapefruit Juice and
coronary artery disease, Alcohol increase effects
aortic stenosis,
of hypotension. Avoid
congestive heart failure,
natural licorice. Take
hepatic impairment and without regard to meals.
in elderly patients.
May take with food to
decrease GI stress.
Hypoglycemia, caution Rapid Acting, Onset: 0with infection, illness, or
15 minutes, Peaks: 1stress, hypokalemia,
2hours, Duration
renal impairment, or
<5hours. Do not skip
hepatic impairment.
meals and administer
insulin.
Respiratory distress.
Take with meals or milk
Caution if GI
to decrease GI irritation.
obstruction, hepatic
Dry mouth,
impairment, and seizure
constipation, nausea,
disorder.
and vomiting may
occur.
Caution with long-term
Take 30-60 minutes
use, high dose treatment
before a meal. Follow
hepatic impairment,
by cool water. May
hypomagnesemia, and
decrease absorption of
patients over 50 years
iron and vitamin B12.
old.
May decrease calcium
absorption. Calcium
citrate is better absorbed
with PPI’s.
43
Avoid gingko and St.
Johns Wort, may
decrease drug level.
May need iron, vitamin
B12, or Folate
supplement. Nausea,
vomiting, and diarrhea
may occur.
Procrit
(Epoetin Alfa)
Cancer Chemotherapy
Hypersensitive to drug,
albumin, or mammalderived products.
Uncontrolled
hypertension.
Reglan
(Metoclopramide)
Nausea, and
Gastroesophageal
Reflux
Seizure disorder, GI
bleeding or perforation,
or GI obstruction.
Caution with depression,
hypertension, congestive
heart failure, cirrhosis,
diabetes mellitus, renal
impairment, and elderly
patients.
Take half hour before
meals and bedtime. Dry
mouth, increased gastric
emptying, nausea,
diarrhea, and
constipation may occur.
May increase appetite.
Zofran
(Ondansetron)
Prevent chemotherapy
associated nausea and
vomiting
Caution with hepatic
impairment, abdominal
surgery, and PKU.
Take half-hour before
chemotherapy, dry
mouth, abdominal pain,
constipation, and
diarrhea, may occur.
44
Appendix Figure 1
QuickTime™ and a
decompressor
are needed to see this picture.
45
Appendix Figure 2
QuickTime™ and a
decompressor
are needed to see this picture.
46
Appendix Table 1
TNM Staging System
Primary Tumor (T)
Tx
T0
Tis
T1, T2, T3, T4
Regional Lymph Nodes (N)
Nx
N0
N1, N2, N3
Primary tumor cannot be evaluated
No evidence of primary tumor
Carcinoma in situ
Size and/or extent of the primary tumor
Regional lymph nodes cannot be evaluated
No regional lymph node involvement
Involvement of regional lymph nodes. Number of
lymph nodes and/or extent of spread
47
Distant Metastasis (M)
MX
M0
M1
Distant metastasis cannot be evaluated
No distant metastasis
Distant metastasis is present
* Example T3 N2 M0 refers to a large tumor that has spread outside of the tissue to the nearby lymph nodes but
not to other parts of the body.
Appendix Table 2
Types of Pancreatic Tumors
Common Non-Endocrine
Adenocarcinomas:
- Most common type of pancreatic caner, accounting for greater than 75% of all
pancreas cancers.
- Adenocarcinomas form glands. These glands are collections of cells
surrounding an empty space. This type of tumor can grow large and invade
nerves causing back pains. This type of cancer also frequently metastasizes to
the liver and lymph nodes. When this tumor metastasizes it may be considered
unresectable.
Rare Non-Endocrine Tumors
Acinar Cell Carcinomas:
- This rare cancer may produce excess amounts of digestive enzymes normally
produced by the pancreas.
- Increased enzymes cause distinct symptoms in 20% of acninar cell carcinoma
cases; symptoms include unusual skin rashes, joint pain, and an increased
level of eosinophils.
Adenosquamous Carcinomas:
48
-
This type of pancreatic cancer is similar to adenocarcinoma because it too
forms glands.
- The cancer cells tend to flatten as they grow.
Colloid Carcinomas:
- Colloid Carcinoma is a distinctive tumor of the pancreas associated with
better prognosis that adenocarcinoma.
Giant Cell Tumors:
- Giant cell tumors have unusually large cells. The tumor is not necessarily
larger just the cells are larger.
- These tumors are no called Undifferentiated Carcinomas with Osteoclast-like
Giant Cells.
Hepatoid Carcinomas:
- These types of pancreatic tumors are extremely rare.
- The cells that form this type of cancer resemble cells of a liver cancer.
Intraductal Papillary-Mucinous Neoplasms:
- The tumors characteristically grow along the ducts of the pancreas that drain
the pancreatic fluid into the small intestine.
- It is believed this type of cancer starts as a curable lesion, however if
untreated may progress to invasive pancreatic caner.
Mucinous Cystic Neoplasms:
- Rare, cystic, fluid containing tumor of the pancreas.
- These tumors can develop into cancer over time.
Pancreatoblastomas:
- Rare malignant tumors, which primarily occur in children.
- Often referred to as pancreatic caner of infancy.
Serous Cystadenomas:
- These tumors are rare and usually benign growth.
- These tumors are cystic, fluid containing tumors with a sponge like
appearance.
- Serous Cystadenomas can grown to be large and may need to be removed if
symptoms such as pain and weight loss occur. Most patients are cured with
the removal of this tumor.
Signet Ring Cell Carcinoma:
- This is a rare form of pancreatic cancer, composed of infiltrating individual
cells with a large mucin vacuole.
- A large mucin vacuole pushes the nucleus to the side, causing the cell to
appear in a ring-like shape.
Solid and Pseudopapillary Tumors:
- These are rare tumors that occur primarily in women in their thirties.
- Some parts of the tumors are solid while other parts of the tumor are papillary.
- Although these tumors are considered cancers, they have a good prognosis.
- These tumors can spread and should be completely removed.
Undifferentiated Carcinomas:
49
-
This is an extremely aggressive form of pancreatic cancer.
The cells do not resemble any normal cell type in the body.
Endocrine:
Endocrine Islet Cell Tumors:
- These tumors are very uncommon, accounting for about 1% of pancreatic
cancers.
- Endocrine tumors may produce highly active hormones and therefore have
very dramatic symptoms.
o Insulinomas producing large amounts of insulin resulting in
hypoglycemia
o Glucagonomas producing glucagon resulting in a very distinctive rash.
Appendix Table 3
Patient’s Lab Values
Labs
Reference
Range
10/6
10/7
10/9
10/10
10/14
10/17
10/18
10/19
10/22
10/23
Na
136-145mg/dL
137
135L
138
136
136
136
137
136
132L
135L
K
3.5-5.1mg/dL
3.3L
4.5
3.4L
3.6
3.7
3.7
3.3L
4.1L
4.5
3.8
Cl
98-107mg/dL
104
100
105
102
100
104
103
103
98
97L
Ca
8.5-10.1mg/dL
7.0L
7.7L
7.4L
7.2L
7.9L
7.6L
7.6L
8.4L
8.2L
8.0L
Phos
2.5-4.9mg/dL
Mg
1.8-2.4mg/dL
1.8
Glucose
74-106mg/dL
336H
378H
Total Bilirubin
0.201.00mg/dL
0.0-0.2mg/dL
13.37H
Direct
Bilirubin
Indirect
Bilirubin
Ammonia
0.101.00mg/dL
<32mcg/dL
1.6L
1.3L*
1.4L*
1.7L
1.8
188H
188H
249H
168H
127H
14.69H
7.37H
5.97H
8.93H
8.22
11.85H
6.08H
2.84H
1.29H
44H
1.8
293H
152H
42L
7.54H
6.62H
7.55H
4.41H
6.34H
5.34H
1.56H
1.20H
1.28H
42H
50
Alk Phos
50-136units/L
312H
382H
382H
297H
490H
420H
434H
659H
631H
AST
15-37units/L
123H
113H
76H
497H
490H
420H
434H
659H
631H
ALT
12-78units/L
112H
121H
88H
73
214H
191H
185H
166H
135H
Albumin
3.4-5.0mg/dL
1.3L
1.6L
1.2L
1.7L
1.4L
1.1L
1.2L
1.3L
1.3L
Prealbumin
20-40mg/dL
4L
Triglyceride
<150mg/dL
172h
B Natriuretic
Peptide
0-100pg/mL
221H
CA 19-9
Antigen
WBC
<34units/mL
52704H
Hct
4.510.0gM/dL
4.005.20gm/dL
11.615.0gm/dL
35-45gm/dL
Plt Count
30-400gm/dL
RBC
Hgb
9.8
11.5H
8.2
7.2
12.0H
3.5L
5.4
6.0
7.6
8.1
3.66L
3.69L
3.57L
3.10L
2.81L
2.63L
3.71L
3.67L
3.70L
3.52L
11.0
11.8
10.7L
9.3L
8.4L
7.9L
11.5L
11.1L
11.5L
11.1L
32.4L
35.7
31.9L
27.3L
25.1L
23.6L
33.2L
33.2L
34.2L
32.7L
103L
130L
98L
91L
61L
16L*
27L*
11L*
20L*
67L
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