Welcome to the Pancreatic Cancer Program at Virginia Surgery Associates (VSA); one of the latest subspecialty programs added to the wide array of subspecialties at VSA. Although pancreas surgeries were performed by Dr. Timothy R. Shaver at VSA for the past decade, the program’s concept was not established until Dr. George Younan, a fellowship-trained pancreatic surgeon, joined his mentor, Dr. Shaver in August of 2016. Together they created one of the fastest growing and busiest programs in the Northern Virginia area.

This website has been designed for patients who have been diagnosed or are being treated for pancreatic cancer, as well as patients carrying a high risk of being diagnosed with pancreatic cancer. How pancreatic cancer is prevented, diagnosed and treated has been summarized. We shed light on the only pancreatic cancer screening program in the Northern Virginia area and explain how this is done.

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Meet the Pancreatic Cancer Program Team

The Pancreatic Cancer Program includes a multidisciplinary team dedicated to the different stages of caring for the pancreatic cancer patients.

Dr. Timothy R. Shaver, a fellowship-trained transplant surgeon has been in the area more than 25 years and has currently practiced HPB surgery with VSA for the last decade.

Dr. George Younan has been with VSA for the last 2 years. He is a fellowship-trained HPB surgeon who finished his fellowship at the Medical College of Wisconsin under the world-renowned Douglas. B Evans, a world authority in pancreatic cancer surgery.

The program’s advanced care practitioner is Danielle Eganhouse, a physician assistant who joined the group in the fall of 2017.

Carrington Jones, is the HPB Program’s Coordinator that has been with VSA for the last 5 years. She will assist with all scheduling and coordinating patient care.

Candice Dickson, BSN, RN is the HPB Program’s designated nurse with experience in adult critical care who joined VSA in the summer of 2018. Her role in the program is to triage patient phone calls and help patients coordinate their care.

Christine A. Gilloon, VSA’s Registered Dietitian and Certified Diabetes Educator, has 23 years of experience, working with patients to provide nutrition education. She works along side the Pancreatic Cancer Program team to coordinate every facet of your treatment program.

The program has a dedicated operating room team under the direction of Chief Anesthesiologist, Dr. Umadevi Rangarajan and a specialized group of surgical technicians, scrub nurses, circulating nurses and OR team leaders.

What is the Pancreas

What is the Pancreas?

The pancreas is a very important organ found deep in the abdomen; it produces insulin to control blood sugar levels, in addition to making pancreatic juice that contains pancreatic enzymes that help with digestion. It is located deep in the abdomen, behind the stomach and on top of the spine in the back.

Pancreas Anatomy

The pancreas is divided to a head and neck part, which is the big bulky part of the pancreas gland, the body and the tail. Pancreatic juice is secreted into a series of ducts that make the main pancreatic ducts that empties into the first part of the intestines called the duodenum. It is located deep in the abdomen, behind the stomach and on top of the spine in the back.

Common Symptoms of Pancreatic Diseases

Pancreas disease symptoms vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include:

  • A dull type pain beneath the breast bone that radiates to the back. In benign diseases of the pancreas like pancreatitis, the pain is due to the
    inflammation of the pancreas gland. In tumors or cancers of the pancreas, pain is usually due to compression of the tumor to surrounding organs in the abdomen.
  • Nausea, upset stomach, or vomiting
  • Jaundice (a buildup of bile chemicals in the blood), which causes yellowing of the skin and eyes, dark urine, and itching. This is usually caused by a blockage of the bile duct that carries bile from the liver to the intestine.
  • Weight loss, poor appetite and aversion to food.
  • Fatigue, depression.

Pancreatic Tumors

Tumors of the pancreas originate from multiple types of cells that constitute the pancreas. Not all pancreas tumors are malignant and some of them can be pre-malignant or benign. Tests and sometimes biopsies need to be done to assess for malignancy. The most common type of pancreatic malignant tumors originates from pancreas cells that line the pancreatic duct, and it is called pancreatic ductal adenocarcinoma. Another type of cells called endocrine cells give rise to a tumor called pancreatic neuroendocrine tumor.

Treatment and prognosis of these two different pancreatic tumors differ significantly, thus the importance of understanding which type of tumor the patient has. Pancreatic papillary pseudotumors are a rare entity with a malignant potential.

Risk factors for pancreatic cancer include smoking, prolonged history of chronic pancreatitis, certain familial cancer syndromes, obesity, diabetes.

Pancreas Anatomy

The pancreas is divided to a head and neck part, which is the big bulky part of the pancreas gland, the body and the tail. Pancreatic juice is secreted into a series of ducts that make the main pancreatic ducts that empties into the first part of the intestines called the duodenum. It is located deep in the abdomen, behind the stomach and on top of the spine in the back.

Common Symptoms of Pancreatic Diseases

Pancreas disease symptoms vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include:

  • A dull type pain beneath the breast bone that radiates to the back. In benign diseases of the pancreas like pancreatitis, the pain is due to the
    inflammation of the pancreas gland. In tumors or cancers of the pancreas, pain is usually due to compression of the tumor to surrounding organs in the abdomen.
  • Nausea, upset stomach, or vomiting
  • Jaundice (a buildup of bile chemicals in the blood), which causes yellowing of the skin and eyes, dark urine, and itching. This is usually caused by a blockage of the bile duct that carries bile from the liver to the intestine.
  • Weight loss, poor appetite and aversion to food.
  • Fatigue, depression.

Screening for Pancreatic Cancer

Virginia Surgery Associates offers a comprehensive Pancreatic Cancer Screening Program to:

  • Reduce risk and implement prevention strategies
  • Identify and offer early detection of pancreatic cancer in high risk patients
  • Offer early treatment options once diagnosed thus improving survival from the disease

Our Program Includes:

  • A multidisciplinary team who works together to assess an individual’s risk of developing pancreatic cancer
  • Regular evaluations, genetic counseling, and for patients who are deemed to be high risk; annual monitoring byradiologic studies such as an MRI or Ultrasound (EUS) of the pancreas

Pancreatic Cancer Facts

  • Pancreatic cancer accounts for about 3% of all cancers and 7% of all cancer deaths in the U.S.
  • The average lifetime risk for pancreatic cancer is 1.5% (or 1 in 63) among men and women
  • By the end of 2018, 55,440 people in the U.S. were diagnosed with pancreatic cancer and 44,300 will die of the disease
  • It is the fourth leading cause of cancer deaths
  • Early detections and multi-modality treatment improve survival

Who is at risk?

  • NCCN guidelines suggest genetic testing for any pancreatic cancer patient as of 2018
  • Certain genetic syndromes and a family history of pancreatic cancer
  • Hereditary syndromes include: Breast and Ovarian Cancer Syndrome, Hereditary Colon Cancer (HNPCC), Familial Atypical Multiple Mole Melanoma, Peutz-Jeghers Syndrome, BRCA 1 and 2 patients
  • Two or more first degree relatives or three or more any relative with a pancreatic cancer diagnosis

For more information or to schedule an appointment with our Pancreatic Cancer Screening Program, please call (703) 359-8640.

Diagnosis and Treatment

Diagnosis and Treatment of Pancreatic Cancer

Signs and symptoms of pancreatic cancer include:

  • Jaundice
  • Weight loss
  • Decreased appetite
  • New onset diabetes
  • Abdominal or back pain

Tests done to diagnose pancreatic cancer include:

  • Blood tests: pancreatic cancers can produce certain types of chemicals called tumor markers like Carbohydrate Antigen 19-9 (CA19-9) or Carcinoembryonic Antigen (CEA), these are not diagnostic but can be used to track tumors.
  • Scans: Computed Tomography (CT), Magnetic Resonance Imaging (MRI), or Positron Emission Tomography (PET) are multiple imaging techniques used to detect pancreatic tumors including size and location, in addition to sites of disease spread to other areas of the body.
  • Endoscopic Retrograde Cholangiopancreatography (ERCP): this is an endoscopic test done by your gastroenterologist, usually used to diagnose and sometimes treat blocked bile ducts by placing a stent inside of the duct in order to drain the liver and treat jaundice.
  • Endoscopic Ultrasound and Fine Needle Aspiration (EUS/FNA): this is also an endoscopic test done to visualize the tumor using an ultrasound probe mounted on the tip of an endoscope, this can scan the pancreas from inside the stomach or the intestine and get biopsies for diagnosis.

Treatment of pancreatic cancer should be performed by a team of specialists in various medical disciplines, including surgeons/surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, endocrinologists, radiologists, nutritionists and support groups. Pancreatic cancer treatment is a multimodality treatment and includes surgery, chemotherapy and sometimes radiation therapy. Recent advances include immunotherapy if other treatments fail, in addition to palliative therapy.

Chemotherapy

  • Most pancreatic cancer patients will require chemotherapy at some point in their treatment. Current recommendations suggest chemotherapy being given after surgical resection is achieved, in tumors that can be surgically resected. We have moved to give chemotherapy to patients who have a tumor that cannot be fully removed by surgery, and then offer surgery if the tumor responds to chemotherapy.

Radiation Therapy

  • Similar to chemotherapy, radiation therapy is an important part of the multimodality approach to pancreatic cancer, it might be given before or after surgery depending on the stage of the disease.

Surgery

  • Surgery pancreatic cancer is done for curative or palliative reasons. As a curative surgery, the goal is to surgically remove the cancer in its entirety. Palliative surgery is done of the tumor cannot be fully removed, then bypass procedures will be done to correct the bile duct obstruction and the stomach obstruction that are resulted from involvement by the neighboring tumor.

Pancreatic Surgery

The extent of surgery of the pancreas is mainly dictated by the location of the disease, or whether it is done for tumors or pancreatitis. Pancreas surgery is one of the biggest and most involving surgeries in the abdomen, and that is due to the proximity of the pancreas to vital organs, in addition to important blood vessels.

The Whipple Procedure

For some patients who happen to have the disease in the head or neck of the pancreas, a Whipple procedure is indicated. The classic Whipple procedure is named after Allen Whipple, who was the first surgeon to perform the operation in 1935. The procedure is also known as
pancreaticoduodenectomy, and it involves removal of the head of the pancreas, the first part of the small intestine (duodenum), in addition to a
part of the bile duct, gallbladder, and a small part of the stomach. The pancreas, bile duct and the stomach are then reconnected to the intestines.

Total Pancreatectomy

Very rarely, certain tumors involve the whole gland and thus a total pancreatectomy is required.

Distal Pancreatectomy

When the disease is found in the body or the tail of the pancreas, surgery is usually shorter and less challenging as it involves less organs. The body and tail of the pancreas are removed in addition to the spleen most of the time as it would be close and involved by the disease. Distal pancreatectomy can be easily done using minimally invasive surgery, using the small incisions camera technique, and we recently started performing these procedures using robotic surgery.

Nutritional Support

VSA’s Pancreatic Cancer Program offers Medical Nutrition Therapy to patients experiencing pancreatic cancer comorbidities. Pancreatic cancer patients occasionally experience symptoms from pancreatic exocrine insufficiency (decreased pancreatic enzyme production), malnutrition, or new onset diabetes (pancreatic endocrine insufficiency) as a result of their disease or its treatment.

VSA’s Dietitian works with patients to provide nutritional education, pancreatic enzyme replacement therapy, and specific diet recommendations to fit our patients’ individual needs. We partner with primary care providers and local diabetes educators to assist our patients in managing their blood sugars post-operatively. Our experienced team members work exclusively with pancreatic cancer patients to help them improve their overall nutrition, health, and quality of live.

Our Nutritional Counseling Services Include:

  • Post-operative dietary counseling
  • Diabetic Nutritional Counseling
  • Pancreatic Enzyme Supplementation/Replacement Therapy
  • Malnutrition counseling

Exocrine Pancreatic Insufficiency

Exocrine Pancreatic Insufficiency (EPI) is a medical term to describe when the pancreas is not able to produce a sufficient amount of digestive enzymes. Digestive enzymes are proteins that help your body break down food in your digestive tract and convert it into smaller nutrients that are usable by the body.

EPI is associated with certain diseases and conditions that affect the pancreas, such as:

  • Chronic Pancreatitis (inflammation of the pancreas)
  • Cystic Fibrosis (a genetic condition that affects the lungs and digestive systems)
  • Pancreatectomy (surgical removal of all or part of the pancreas)
  • Gastrointestinal Surgery
  • Pancreatic Cancer and Diabetes
  • Radiation and/or chemotherapy to pancreas

Symptoms include:

  • Gas
  • Bloating
  • Stomach Pain
  • Frequent Diarrhea
  • Frequent Bowel Movements
  • Unexplained weight loss

Over time, if EPI is not managed it can lead to vitamin deficiency and malnutrition which could result in:

  • Night blindness
  • Osteoporosis
  • Muscle mass loss
  • Increased risk of cardiovascular events
  • Weakened immune system
  • Possibly pre-mature death

Treatment for EPI requires an experienced medical team and often includes prescribed Pancreatic Enzyme Replacement Therapy. PERT works by supplying the digestive tract with the enzymes that the pancreas is no longer able to produce and often alleviates
or resolves symptoms of EPI.

Surveillance, High Risks Pancreatic Cysts

Pancreatic Cysts

Pancreas cysts are common findings on imaging studies. Certain cysts are benign in nature and do not require surgery however other cyst can be premalignant in nature and can degenerate into cancers, some of these include Intraductal Papillary Mucinous Neoplasms (IPMN), or Mucinous Cystic Neoplasms (MCN). There are specific indications for surgery when a pancreatic premalignant cyst is diagnosed. Pancreatic pseudocyst are also cystic lesions of the Pancreas resulting from inflammation of the pancreas, these do not carry a malignant potential, however they can cause local compression symptoms and can require surgery.

Resources

Resources

Pancreas cysts are common findings on imaging studies. Certain cysts are benign in nature and do not require surgery however other cyst can be premalignant in nature and can degenerate into cancers, some of these include Intraductal Papillary Mucinous Neoplasms (IPMN), or Mucinous Cystic Neoplasms (MCN). There are specific indications for surgery when a pancreatic premalignant cyst is diagnosed. Pancreatic pseudocyst are also cystic lesions of the Pancreas resulting from inflammation of the pancreas, these do not carry a malignant potential, however they can cause local compression symptoms and can require surgery.