[Medical Insight 66th] Symptoms and treatments of "pancreatic cancer" by a gastroenterologist.

□ Broadcast date and time: January 10, 2025 (Fri) 10:20 p.m.
□ Producer in charge: Lee Siwoo
□ Author in charge: Kim Bae-jeong and Kim Hyun-jeong
□ Cast: Chun Young-guk (Geonkuk University Hospital, gastroenterologist)
□ Broadcast channel
IPTV - GENIE TV No. 159 / BTV No. 243 / LG Uplus No. 145
SkyLife Number 90
Cable - Delive No. 138 / Hyundai HCN No. 341 / LG HelloVision No. 137 / BTV Cable No. 152

* The text below may differ from the actual broadcast content, so please check the broadcast for more accurate information.


◆ CHAN YONG KYUNG: Hello, I'm CHAN YONG KYUNG, a gastroenterologist. What I've prepared in this time is pancreatic cancer.

◇ Voice actor Park Sang-hoon: Pancreatic cancer, a disease that should be suspected at least once when you lose weight, have jaundice symptoms, and have oily stools due to fatty stools. Because the pancreas is located deep in the abdomen, early detection of cancer lesions is difficult, with less than 20% of the cases found in the early stages of surgery, and as a result, the 5-year survival rate of pancreatic cancer is very low at 15.9%. Smoking is the number one risk factor for pancreatic cancer. Smokers are three times more likely to have pancreatic cancer than non-smokers, and pancreatic cancer with the worst prognosis among the top 10 cancers in Korea. Let's take a closer look at pancreatic cancer, which is called silent cancer.

<Pancreatic Locations and Structures>
◆ Chun Young-guk: Before we talk about pancreatic cancer, let's first look at where the pancreas is located in our body and what it's functioning. The pancreas runs sideways in our body, behind the stomach, and in front of the vertebrae. It is mainly located to the left from the center. So it's located relatively deep in the abdominal cavity of our body. Because it is deep in the body, it is not well observed, and a wide variety of blood vessels are formed around the pancreas, so when pancreatic cancer occurs, it invades the blood vessels relatively early and the cancer spreads through this blood vessel to other organs, which is why the prognosis is poor. I think you can understand the shape of the pancreas well if you think of sweet potatoes. It looks similar to the shape of a sweet potato. So, if you look at the structure, the front is called the head of the pancreas, the middle of the head is called the tail, and the middle of the head is called the tail. Symptoms vary slightly depending on the location of pancreatic cancer. Also, if you make an incision in the pancreas, the pancreas consists of two structures: pancreatic tissue flesh and the pancreatic duct, which is a moving path for digestive fluid to flow down.

<Function of the pancreas>
◆Cheon Young-guk: So what does the pancreas do? The pancreas can be largely divided into two functions: the exocrine function to secrete digestive fluid and the endocrine function to secrete hormones. This digestive fluid is produced at 95% of the total pancreatic volume and secreted through the pancreatic duct to the duodenum. This pancreatic digestive fluid contains digestive enzymes that break down protein fat and carbohydrates. So when you eat food, these various ingredients in the food come out to help break down and absorb pancreatic digestive juices. If it hurts the pancreas, these digestive enzymes will lose their secretion. Of course, that's why it's hard to digest and the patient loses weight due to poor nutrition. More importantly, there is a lipase called lipase, a lipolytic enzyme. If the amount of this lipase comes out small, this fat component cannot be digested. When fat components are indigestible, it becomes very gasy and bloated. And when you look at your stool, the smell gets worse and fat gets stuck in your stool. So if you go to the stool one day and your stool smells so bad and you have fat in it, don't you think there's something wrong with your pancreas? ’ You'd better think about it. Another important function is that this pancreatic digestive fluid is alkaline. You know it well, right? Doesn't it produce stomach acid from the stomach? It is mixed with stomach acid made in this stomach acid because it is eaten, and the oxidized food eventually descends to the small intestine. Unlike the gastric mucosa, this small intestine is very thin. So, when oxidized food comes down like this, the mucous membrane of the small intestine is thin, so you can get injured, inflammation, bleeding, and in severe cases, perforation. So when the oxidized food comes down to the duodenum, this pancreas reacts immediately and secretes this pancreatic fluid. Because this pancreatic fluid is alkaline, it is mixed with oxidized food and neutralized. That's why it protects the small intestine. This will now be an exocrine function. Second, the endocrine function is to secrete hormones. It is produced by endocrine cells within 5% of the total volume of the pancreas and secreted into blood vessels. Representatively, insulin and glucagon are included. Insulin is secreted by the pancreas to lower blood sugar levels when blood sugar rises due to eating food or eating too sweet. This elevated blood sugar is converted into a substance called glycogen, stored in the liver, and converted into fat to convert it into body fat. That's why you lower your blood sugar. What you can see here is what happens if you eat too much or if you eat too much blood sugar or foods high in sugar? Eventually, glycogen increases so much that fatty liver is formed, and there is a lot of conversion to fat, so body fat increases and you become obese. So it's better not to eat proper meals and foods with high blood sugar like this. Glucagon works the opposite way to insulin. If we fast for too long or if we have low blood sugar for some reason, we have hypoglycemia symptoms. Since this blood sugar is too low, it takes out stored glycogen and breaks down fat cells to restore insufficient blood sugar.

<classification of pancreatic cancer>
◆Cheon Young-guk: So far, we've looked at where the pancreas is located in our bodies, and then what it functions. I think you understood it well. Now, let's take a look at pancreatic cancer in earnest. Pancreatic cancer is largely divided into two histologically. If you say pancreatic cancer that you know, it's pancreatic adenocarcinoma. This pancreatic adenocarcinoma accounts for 90% of all pancreatic cancers. Pancreatic endocrine cancer is a cancer that occurs in endocrine cells that secrete pancreatic hormones. It accounts for 10% of all pancreatic cancers.

<Pancreatic Cancer incidence>
◆Cheon Young-guk : Let's look at the frequency of pancreatic cancer. This is what Korean statistics announced. For men, gastric cancer, colon cancer, and lung cancer rank first, second, and third. In women, thyroid, breast, and colon cancer are by far the most common. Pancreatic cancer is seventh in men and ninth in women. Fortunately, it's a relief that the frequency is not high. But what's the problem? Pancreatic cancer now has the highest mortality rate among all cancers compared to low stomach cancer or colon cancer. So many people still think that they will die if they get pancreatic cancer, right? The death rate is high. Whether it is all cancer, stomach cancer, or pancreatic cancer, if it is detected and treated early, the cure rate is very high.

<Examination of pancreatic cancer>
◆ Chun Young-guk: Is early screening possible for pancreatic cancer? This early examination is an easy examination. It's a way to find cancer by examining it with chest X-Ray, ultrasound, and hematologic tests that you know well. In the case of stomach cancer, it's an endoscope. However, a test method for early screening for pancreatic cancer has not yet been established. You've been doing a lot of check-ups recently, right? If you look at this examination, there is a 'tumor marker' among the hematologic tests. Among them, there is now a 'pancreatic cancer tumor marker'. Can it be used as an early screening for pancreatic cancer? That's not true. Recently, pancreatic cancer has focused on surveillance because this screening is still disappointing for early screening. So most of the risk factors are the tip of the iceberg. It's hiding deep in the sea over there. So, the main focus is to find out which people can get pancreatic cancer and monitor them intensively.

<Risk Factors for Pancreatic Cancer>
◆ Chun Young-guk: So let's start looking at the risk factors for pancreatic cancer in what people are more likely to develop. The first acquired cause is tobacco. It's smoking. It is already known that
tobacco smoke and nicotine contain a wide variety of cancer-causing substances. Therefore, it is said that smoking will be a direct factor in pancreatic cancer and is more than five times more dangerous than ordinary non-smokers. Therefore, if you smoke, you'd better quit smoking as of this time today. The second is diabetes. Diabetes can be the cause or effect of pancreatic cancer. The cause is that people who have been suffering from diabetes for a long time, especially those who are treated with insulin, are at a slight risk of pancreatic cancer. The reason is that if we continue to receive insulin treatment, our body says, 'Oh, we lack insulin.' So we make hormones to make insulin. That's what's called the insulin growth factor. There are reports that if this insulin growth factor is unnecessarily made over and over again, it can stimulate the pancreas and cause pancreatic cancer. The next result of pancreatic cancer is that when pancreatic cancer occurs, the normal pancreas is damaged. Insulin secretion function decreases because normal pancreatic cells are reduced due to injury. So, this is called new diabetes in adults because blood sugar is generated. According to reports, there is a 30% chance of pancreatic cancer in this new diabetes in adults. So if you have diabetes, you need to be a little careful. Next, chronic pancreatitis. In fact, drinking itself is not directly related to pancreatic cancer. But what's the problem? If you drink repeatedly, you can eventually develop acute pancreatitis, and if this acute pancreatitis is repeated, it develops into chronic pancreatitis, which is a permanent damage. Developing this chronic pancreatitis increases the risk of pancreatic cancer more than three times. So it's better to refrain from drinking frequently. Also, for those with chronic pancreatitis, it is recommended to have a regular pancreatic examination by CT. Next is genetic factors. These days, all cancers are genetically approached and explained. In fact, this genetic mutation is actually the most important factor for cancer risk factors. Various genes are involved in the process of the normal person progressing to cancer. But our bodies are amazing. We already have a tumor expression gene in our body that can cause cancer. However, there is another gene that usually suppresses tumors. So the two things are tightly balanced. However, if this balance is broken for some reason, cancer can occur when the tumor expression gene is excessive or the tumor suppressing gene is mutated and function is lost.

<Symptoms of pancreatic cancer>
◆ CHEN ENGLAND: So now let's look at the symptoms that might suspect pancreatic cancer. There are five typical things. Abdominal pain, jaundice, indigestion, weight loss, and then diabetes. Just because you have abdominal pain, you don't have to suspect pancreatic cancer. Abdominal pain related to pancreatic cancer has a very characteristic finding. It's not this diffusely painful, but it's just a little bit above the upper abdomen navel as if you're tearing it out. In some cases, there is a pain that seems to be squeezed in the upper abdomen like this, and the back also complains of pain. The second is jaundice. Sometimes when I look in the mirror, my eyes are white, or when I pee, my urine suddenly turns reddish one day. Then you have to suspect jaundice. Pancreatic cancer, in particular, is most common in the head of the pancreas. The biliary tract passes through the head of the pancreas. Then this pancreatic cancer digs into the biliary tract and blocks the biliary tract, so the bile eventually cannot come down to the duodenum, causing jaundice. So, especially if you have jaundice without symptoms and without a fever, you should suspect pancreatic cancer and test it. Now, the third thing is weight loss. The first thing to think about and examine when you have indigestion is now the gastrointestinal side. But even though I did endoscopy and took digestive medicine, I still can't digest it. In that case, we have to suspect the pancreas next. Why is that so? As I explained at the beginning, the pancreas secretes various digestive enzymes. Eventually, if pancreatic cancer occurs and the pancreas is injured, these digestive enzymes will not come out, which will inevitably lead to digestive problems. And because the nutrients are decomposed and cannot be absorbed, the patient keeps losing weight. Even with a proper meal. So when you have these symptoms, you should suspect pancreatic cancer again. I explained diabetes a while ago. People who have been using insulin for a long time or who have been healthy should suspect pancreatic cancer even if an adult suddenly develops diabetes.

<Diagnosis of pancreatic cancer>
◆Cheon Young-guk: Now, let's look at the diagnosis of pancreatic cancer. But the first thing you can do easily is blood tests. Blood tests are performed first. Blood tests are performed, especially liver function tests. You said earlier that pancreatic cancer can cause jaundice. When jaundice occurs, we have elevated levels of bilirubin in the hematologic liver function test, and the liver enzyme levels of GOT and GPT are elevated. And serum tumor markers. Pancreatic cancer tumor markers are also tested. Even if you have pancreatic cancer, this number doesn't actually go up. It goes up in about 70% of pancreatic cancer patients. If the level rises a lot, pancreatic cancer is suspected, but the prognosis is said to be poor. Abdominal ultrasound is too easy to examine and does not harm the patient, so it can be screened first. The picture on the left will be the ultrasound findings of the normal pancreas. So in the middle of the gray color, what looks like a peanut like this would be a normal pancreatic tissue. On the right side, the black arrow appears between the normal pancreas, indicating pancreatic cancer. So I told you that some parts of the pancreas' body and then the body can be diagnosed with ultrasound to some extent, but there is a limit to the very front or the crooked side. So the earliest important test for pancreatic cancer diagnosis is CT. CT will be a test that focuses on finding the presence or absence of pancreatic cancer. Next, if you look for pancreatic cancer, we are conducting additional MRI tests to determine whether the pancreatic cancer has spread to other places, whether it has invaded blood vessels or nerves, and then to determine the surrounding lymph nodes in more detail. Next, there is a biliary endoscopy among endoscopy. This is no longer used as a diagnosis these days. When pancreatic cancer blocks the biliary tract and causes jaundice, it is often used for the purpose of treatment. However, for diagnostic purposes, it can be a useful test method for pathological confirmation by performing a biopsy on the blocked area. If you look at that picture, the picture on the left is the findings of a biliary tract plastic surgery seen with a normal biliary tract endoscope. It comes down very well in a straight line. But if you look at the picture on the right, pancreatic cancer in the front of the pancreas is invading the biliary tract, showing a blockage in the lower part of the pancreas. Yes, if you look at those findings, you can suspect that 'Oh, that pancreatic cancer is blocking the biliary tract.' There is a test called ultrasound endoscopy that is now in the spotlight. How to do this is that there is an ultrasound at the end of the endoscope. Ultrasound runs and enters the stomach directly, and the pancreas is attached side by side with the stomach. So after inserting the endoscope to the stomach, you can observe the pancreas through the stomach. It will be the smallest arc and the most sensitive way to find pancreatic cancer. Next, in the Department of Radiation Nuclear Medicine these days, there is a PET-CT through radiation isotopes. What is the role of this PET-CT? Rather than diagnosing cancer, it will be a very useful test for diagnosing cancer already in CT and MRI and finding metastatic lesions if there are microscopic areas elsewhere. So, especially when you use it a lot. It's the 1st and 2nd units for surgery. CT and MRI showed no metastasis. However, PET-CT is taken to ensure that the cancer has not spread to other areas that have really spread. If it doesn't show up in this PET-CT, we can tell the surgeon that it's safe to operate because we know it hasn't metastasized. These days, when pancreatic cancer can be operated in the early stages, it is often transferred to surgery without biopsy, but in practice, it is still unfortunate, but pancreatic cancer is often unable to perform stage 3 and stage 4 surgery at the time of diagnosis. In that case, you have to use anticancer drugs. In order to use this anticancer drug, you can only use it if pancreatic cancer is proven histologically. That's why I need to do this biopsy. The pancreas is deep in the stomach. So it's very difficult to do a biopsy outside. And if you do a biopsy outside, it damages surrounding organs, so you can't do a biopsy outside, but you can do a biopsy using an ultrasound endoscope. The pancreas is attached side by side right behind the stomach, so it's a way to go in there, find the lump with an ultrasound endoscope, and then poke a thin needle to get some tissue. This has no risk of bleeding and little risk of cancer spreading to other areas.

<Pancreatic Cancer Treatment>
◆Cheon Young-guk: Now I'm going to talk about the treatment of pancreatic cancer. Treatment of pancreatic cancer varies according to each stage. So what's the best treatment for pancreatic cancer? And if you ask me, it's surgery. But to say, "You can have surgery," I'll tell you that the disease is in its early stages. However, as I said at the beginning, it was not more than 10% of cases were found in the early stages. Anyway, if you are diagnosed with pancreatic cancer and hear that you have to perform surgery, it is a relief in the midst of unhappiness. It is recommended that you perform surgery unconditionally. Another important thing is that pancreatic cancer, when completed by surgery, has a very high recurrence rate compared to other cancers. Therefore, even if you have had clean surgery, it is recommended to lower the recurrence rate and increase the survival rate by performing adjuvant chemotherapy after surgery for a certain period of time. And when you have surgery, there is a factor that says, 'Oh, this person will not relapse well and get good treatment results.' First of all, the smaller the tumor, the better. Next is the differentiation diagram of the tumor. The better that differentiation, the better. More importantly, there should be no lymph nodes around when the surgery is performed. Even if the lymph nodes have been resected cleanly, if there is a finding of cancer metastasizing to the lymph nodes at the time of surgery, it is very likely to recur.

<Surgical Treatment>
◆Cheon Young-guk: So how do you operate? Surgery is performed relatively early in the 1st and 2nd phases. The surgical method of pancreatic cancer is largely different from pancreatic head cancer, followed by pancreatic body and tail cancer. This is because pancreatic head cancer is in the front of the pancreas. The front of this pancreas is the duodenum and a mass. They're attached to each other. Therefore, because the duodenum and pancreas cannot be separated, pancreatic duodenal resection is performed to remove the duodenum and pancreas at the same time. There are no organs around the pancreatic body or tail. So these days, I'm almost performing laparoscopic surgery, not laparoscopic surgery. The pancreatic body or tail is cut off only the tail of the pancreas, just like cutting a fish skewer. However, the spleen is always resected. The reason is that when the pancreas is resected, the spleen arteries that feed the spleen are resected, so the pancreas tail and spleen are resected together.

<Cancer therapy for pancreatic cancer>
◆ Chun Young-guk: What's important is that local advanced diseases are very hot in our medical community these days. It's the 3rd flag.
It refers to the spread of the disease around the pancreas, although it did not metastasize to other organs. This locally advanced disease can be classified into two categories. Although it has progressed locally, there are cases where it is possible to resect and there are cases where it is impossible to resect. What this means is that pancreatic cancer invaded blood vessels in the middle. So if you invade these important arteries that feed the small intestine or the liver, you can't operate without metastasis. Why is that so? If this blood vessel is cut off, the liver dies, or if the blood vessel that feeds the small intestine is cut off, the entire small intestine dies, so we call cases of invading this blood vessel a local progressive disease. In this case, if you preemptively reduce the lump by anticancer, the lump will move away from the blood vessels and the blood vessels will fall out. Then you can have surgery. This is what we call downstage. We're going to make the 3rd generation into the 2nd generation. However, in this case of local progression, the degree of invasion of blood vessels is important. If you partially invade the blood vessels, you can reduce the lump with anticancer drugs and perform surgery, but if this cancer completely invades the blood vessels. Even if the lump is reduced, the blood vessels cannot escape from the cancer, so the surgery cannot be performed in the end. Now, anticancer drugs have changed a lot in pancreatic cancer. Since drugs have increased and the effectiveness has improved, it is recommended to actively treat pancreatic cancer. So at the time of diagnosis, most pancreatic cancers were often in stage 4. Currently, advanced pancreatic cancer is primarily using this drug called polpyrinox, gemcitabin, and nappaclitaxel, which combine four drugs. The effect is showing a very good effect. The survival rate of patients is also increasing compared to the past. So let's look at one example. This is a stage 4 patient whose pancreatic tail cancer has spread to the liver. A large black lump is observed in the tail of the pancreas. It is 6.5cm in size and has a small spread of cancer on the liver. So, I did a follow-up examination after the 6th round of anti-cancer drugs on the polpyrinox drug. The black lump in the pancreatic skewer was reduced to 6.5cm to 2.8cm. The liver's metastasis is gone. In the past textbooks, there is a 10% to less than 15% chance that a patient can live for about six months with stage 4 pancreatic cancer. But this person has been living with anticancer drugs for more than two years now. So, unlike in the past, I will tell you that 'pancreatic cancer has changed to an era of active treatment, whether it is stage 1 or stage 4'.

<Medical AI Q&A>
◆ Chun Young-guk: Well, viewers have sent me a lot of questions about pancreatic cancer. Shall we check it out together?

◇ Y-ON (AI Anchor): Is it likely to develop from pancreatitis to pancreatic cancer?

◆ Chun Young-gook: Just because you have one pancreatitis doesn't mean you're going to have pancreatic cancer. However, if this pancreatitis is repeated, it can develop into chronic pancreatitis. Chronic pancreatitis is a permanent damage to the pancreas. If you fall into chronic pancreatitis, which is a permanent damage, you are more likely to develop pancreatic cancer.

◇ Y-GO (AI Anchor): My mother is having a hard time because she has no energy after surgery for pancreatic cancer. People around me say immunotherapy is good, will it be effective?

◆ [Voiceover] So what's important here is the surroundings. It's important whether the surroundings are medical staff or not. In fact, there's actually a lot of commercial activity going on with cancer patients. It will be important whether or not the immunotherapy is a proven immunotherapy that normally benefits the patient. So, if you want to treat immunotherapy, you should consult with your medical staff and oriental doctors to see if the drug is helpful to you after proper treatment. The reason is. Some of these supplements are metabolized through the liver when others say they like them. However, some drugs can cause so-called toxic hepatitis because they go to the liver and make the liver bad when taking drugs that have not been properly identified. Therefore, it is better to get proper immunotherapy after consulting with the medical staff properly.

◇ Y-ON (AI Anchor): My father was diagnosed with pancreatic cancer, and he said he had cancer cells in his tail. You didn't tell me about the weapon, but would it not be life-threatening if I had surgery?

◆ CHEN YANG-UK: Yes, if you get a test on the head of your longest tail and the medics say, "You can do the surgery." If you say 'let's do surgery', I'm talking about the relatively early days. Then, it is recommended that you have surgery unconditionally. However, as I said earlier, pancreatic tail cancer has developed relatively late and has already spread, so understand the exact stage and if this is stage 1 and stage 2, you have to undergo surgery. Of course, it will not be life-threatening and will be a good way. However, if you listen carefully to the toilet and there is a metastasis elsewhere, it would be better to treat it with anticancer drugs rather than surgery.

<Remember this>
◆ Kim Young-mo: Yes, so far, we've looked at the functions of which bodies are located in the pancreas, and then diagnostic treatments for symptoms that may be suspected in pancreatic cancer. In the past, even now, many teachers and you are afraid and scared of, "If you get pancreatic cancer, you'll all die." Recently, many drugs have been developed and good treatments have been developed. So unlike in the past, pancreatic cancer is now worth fighting and winning. And if you receive proper treatment, you can see a cure. So, don't be too afraid just because you're diagnosed with pancreatic cancer, and I hope you meet with the medical staff and give them hope and active treatment. I hope my story today helped you to live a healthy and happy life. Thank you.