Dr. Miller: Surgical treatments for uncommon pancreatic cancers. We're going to talk about that next on Scope Radio.
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Dr. Miller: I'm here with Dr. Thomas Chaly. He's a pancreatic transplant surgeon, and we're going to talk about other kinds of pancreatic cancers. I think most people, Thomas, are used to knowing about the standard pancreatic cancer, but what we treat here at the University of Utah are more rare types of cancer called neuroendocrine tumors of the pancreas. Can you talk about that a little bit?
Dr. Chaly: Pancreatic neuroendocrine tumors are a rare tumor, like you stated, representing approximately 5% of all tumors of the pancreas.
Dr. Miller: Not common.
Dr. Chaly: Not very common at all. They can be described as in two ways, nonfunctional versus functional, functional being quite more common than the other. The spectrum of these tumors range from insulinomas, glucagonomas, VIPomas. These may just sound like large terms, but basically my point to get across is these are hormone-producing tumors.
Dr. Miller: So tell me what an insulinoma does.
Dr. Chaly: An insulinoma is a tumor that's secreting insulin from the pancreas.
Dr. Miller: That's where insulin is made anyway, right?
Dr. Chaly: Correct.
Dr. Miller: Okay. So if you have diabetes, your insulin-producing cells of the pancreas aren't producing enough, but in this case, too much.
Dr. Chaly: Right. They're overproduced and then they're secreted based on the tumor so it's uncontrolled. It's an uncontrolled tumor secreting insulin in extreme amounts.
Dr. Miller: And then there are other types of neuroendocrine tumors.
Dr. Chaly: Correct. Like glucagonomas, which are increasing the amount of glucose you have in your body in extreme amounts.
Dr. Miller: Almost the opposite of what the insulinoma does.
Dr. Chaly: Exactly. In addition to that, there's also something that's more common on the spectrum, which would be a gastronoma.
Dr. Miller: Would you think that these neuroendocrine tumors are as dangerous as pancreatic cancer as we commonly know it?
Dr. Chaly: I would say they're dangerous in the fact that they act like ninja tumors, as I like to call them.
Dr. Miller: That's interesting. What is a ninja tumor?
Dr. Chaly: Well, tumors of the pancreas, I would say, can go relatively unnoticed for a longer period of time, kind of like a ninja. Now, maybe that's just kind of a term that's a little too broad, but I would say that these tumors are dangerous in that aspect, that they go unnoticed for long periods of time.
Dr. Miller: So they're small. They may not produce much in the way of hormones. People don't notice them, and then later on as they get bigger and produce more hormones, all of a sudden they develop symptoms.
Dr. Chaly: Right. And then at that point, that's when the diagnosis may in some cases be too late. But in other instances, this is just the tip of the iceberg of all their symptoms.
Dr. Miller: One question I have is, are neuroendocrine tumors generally malignant in the sense that they can metastasize or not?
Dr. Chaly: So that's an excellent question, and the answer is 50/50. Most are benign, but some are malignant and in some cases they can metastasize to the liver, which can be very scary to the patient themselves.
Dr. Miller: So to point out to the audience, even though they're benign they still produce hormones like insulin or glucagon and that causes abnormal symptoms in the patient and then has to be treated. So generally, even though they're benign, if they're functional they are taken out or treated.
Dr. Chaly: Right. So there are multiple treatment options, obviously surgical resection being one of the first and foremost. But in addition, there are other palliative measures as well that can temporize the hormone production of all of these tumors.
Dr. Miller: Now, Dr. Chaly, when do you get involved? Are you getting involved when these are malignant and their metastatic?
Dr. Chaly: Well, at this point our division gets involved when these lesions are metastatic to the liver. This indicates what we would call an expanded disease at this point, where they've gone beyond the lymph nodes and beyond the primary tumor sites, and have gone to areas in the liver where maybe not all practitioners are familiar with.
Dr. Miller: Now, that's concerning because when we think about metastatic disease, we think about terminal disease. But you're also saying, maybe not. Maybe we have treatment for that.
Dr. Chaly: Right. There are excellent results here at The U in regards to neuroendocrine tumor resection, in regards to debulking of these tumors, and it has been well-described that these tumors, if debulked and surgically managed, can be beneficial to the patient long-term.
Dr. Miller: Debulking; could you describe that term for them?
Dr. Chaly: It's basically an 80% reduction in the amount of tumor that's in the liver. If you're able to attain an 80% reduction in metastatic volume of the liver, essentially a metastasectomy of the liver, then you are doing a quite significant benefit to the patient's long-term survival.
Dr. Miller: Now, if you leave some of that cancerous tissue in, do you have to go back in later and do another resection?
Dr. Chaly: That's a possibility as well if it continues to grow. Another modality that can be used is interventional radiology and radio frequency ablation, essentially just burning the areas of the liver that would have remnant tumor in certain areas.
Dr. Miller: Now, how do patients with these neuroendocrine tumors, especially ones that are metastatic to liver, find their way to your door?
Dr. Chaly: Well, it's usually a situation where a patient had a primary tumor of the pancreas and it was found to be a neuroendocrine tumor. Then, they were later diagnosed, maybe a year or two later, sometimes less, where they had tumors now in the liver. The original physician maybe thought that a more experienced liver surgeon may have some other modalities that weren't available to him at his initial encounter.
Dr. Miller: Now, I'm curious as to how many of these patients you see a year.
Dr. Chaly: We see quite a number of patients a year. I would say we see close to 100 patients who need liver resections in some capacity. Maybe approximately 20% of those are pancreatic neuroendocrine tumors or neuroendocrine tumors that have metastasized to the liver.
Dr. Miller: Now, I'm thinking that since these are pretty rare pancreatic tumors, patients are coming to see you from all over the place, probably from outside the state, elsewhere. Is that true?
Dr. Chaly: Correct. We're getting patients from all over the surrounding states. They come concerned because of these liver metastases and what we're able to offer them. I would tell that it's not a death sentence by any means. Neuroendocrine tumors that have metastasized to the liver can be treated in a variety of ways. In addition to those that I've mentioned, surgical resection and burning them, liver transplantation is also an option in selective cases.
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