Why is involvement of arteries and veins important in the treatment of pancreatic cancer?

The location of the pancreas deep within the abdomen places it close to numerous large blood vessels that are necessary for life (see “Where is the pancreas?” post).  As a result, cancers of the pancreas do not need to grow very large before invading these vessels and this poses a significant treatment problem. There are two main arteries in the area of the pancreas and these are called the celiac artery and the superior mesenteric artery. The celiac artery gives rise to the splenic artery and the hepatic artery and supplies blood to the liver, pancreas, spleen and stomach. The superior mesenteric artery gives rise to numerous branches that supply the small bowel, part of the colon and the pancreas. The venous system in this area is the portal vein and its tributaries. It drains blood from most of the gastrointestinal track back to the liver and ultimately to the heart through the hepatic veins. Pancreatic cancers that invade these major blood vessels are classified as Stage III which includes two subcategories – “border-line resectable” and “locally advanced, unresectable”.

Cancers that are found to completely surround one of the main arteries as determined by CT scan (“encasement”) are typically considered to not be operable (locally advanced, unresectable). An attempt at removal of such cancers has a very high probability of leaving a portion of the tumor behind (R2 resection) and thus the surgery will confer no survival benefit while potentially subjecting the person to debilitating side effects. Patients with locally advanced, unresectable pancreatic cancer will often undergo radiation and chemotherapy in hopes of shrinking the tumor away from the artery. Unfortunately, significant shrinkage of the tumor that converts it to removable occurs only 10% of the time. A tumor that grows next to one of the main arteries but does not surround it (“abutment”) is considered borderline resectable. In this case there is a good chance it can be removed without cutting though the tumor and, at worst, leaving only a few tumor cells behind (R1 resection). In most centers, including ours, patients with borderline resectable pancreatic cancer will receive radiation therapy prior to surgery in order to kill the cancer cells in the periphery of the tumor. This takes about 6 weeks and increases the likelihood of leaving no cancer behind at the margins (R0 resection). Unlike Stage III locally advanced pancreatic cancer, most patients with Stage III borderline resectable cancer will go on to have their tumor removed by surgery. The main exception to proceeding to surgery in borderline resectable patients is in the event the cancer grows further or develops distant metastases while receiving the chemotherapy and radiation therapy.

The assessment of whether or not a tumor is removable based on invasion of the main veins is very different than that of the arteries. Basically, any degree of involvement of the vein from abutment to encasement is considered to be borderline resectable as long as the tumor involves a portion of the vein that can be reconstructed once that section is removed. For example, if the tumor grows in the mid-portion of the vein (called the portal vein – superior mesenteric vein confluence), the tumor must be taken out with the vein attached and the two end of the vein can be reconnected to restore flow. If the same size tumor grows lower down on this vein (towards the feet), it will involve the portion of the vein that braches like numerous limbs of a tree. Removal of the vein in this area would leave the surgeon with one main “trunk” at the top and numerous “small braches” at the bottom. There would be no way to reconnect the ends. Thus for venous involvement, if it grows at a location in which the surgeon can technically remove the tumor and reconstruct the vein it is called Stage III borderline resectable. If removal and reconstruction is not possible it is called Stage III locally advanced. As described above for the arteries, patients with stage III cancers will most likely receive radiation therapy and most of those in the borderline resectable category will go on to surgery, while only 10% locally advanced will have significant tumor shrinkage.

There are numerous exceptions to this general algorithm based on feature that are unique to each individual patient. The complexity of the many treatment options underscores the need to be evaluated by an experienced team of specialists. We have found that this is best accomplished through a multidisciplinary clinic where patients are evaluated by all of the specialists in a single day. If you would like to learn more about this clinic please feel free to contact us at 410-933-PANC. We will be able to answer your questions and schedule a clinic appointment for you at your request.

Vagus Nerve Stimulation (VNS) and Treatment of Depression: To the Brainstem and Beyond

 Neuromodulation appears to be emerging gradually as a new therapeutic
field in psychiatric treatment. It encompasses neuropsychiatric medical
devices, such as vagus nerve stimulation (VNS), transcranial magnetic
stimulation (TMS), deep brain stimulation (DBS), and electroconvulsive
therapy (ECT). As a therapeutic approach to affective disorders,
neuromodulation shifts the focus from the monoamine synapse to neural
circuitry of the brain, which is dysregulated in depression. This neural
circuitry has been elaborated on over the course of 15 years of
neuroimaging research in mood disorders and is now believed to encompass
disturbances in a frontolimbic network. These include reduced
metabolism and blood flow in the prefrontal cortex and anterior
cingulate and pathologically increased activity in the subgenual
cingulate and amygdala.VNS is an implanted device that has established
efficacy in pharmaco-resistant epilepsy. It was approved by the FDA for
the treatment of severe, recurrent unipolar and bipolar depression in
July of 2005. VNS adopts a bottom-up approach to modulating the neural
circuitry of depression by stimulating vagal afferent fibers in the neck
, which carry impulses to the brain stem to target there the locus
ceruleus and dorsal raphe nucleus. Now that VNS has moved beyond the
experimental phase and into the clinic, psychiatrists are faced with
deciding who is an appropriate patient for this surgical implant and how
to integrate VNS into existing treatment in order to optimize both
efficacy and safety.This review of VNS will assess the efficacy and
safety data that led to the FDA approval. We will also review for the
busy clinician how VNS is likely to translate into clinical practice as
a treatment option for patients in need who are suffering from severe
depression.

MIGRAIN HEADACHE

Migraine can be defined as a paroxysmal affection, accompanied by severe headache, generally on one side of the head and associated with disorders of the digestion, the liver and the vision. It usually occurs when a person is under great mental tension or has suddenly got over that state.

Migraine is also known as "sick headache" because nausea and vomiting occasionally
accompany the excruciating pain which lasts for as long as three days.

Migraine usually gives warning before it strikes : black spots or a brilliant zig-zag line appears before the eyes or the patient has blurring of vision or has part of his vision blanked out. When the headache occurs, the patient may feel tingling, numbness, or weakness in an arm or leg.

Migraine sufferers have what is known as a "migrainous personality ". They are compulsive
workers and perfectionists, who feel that they have to do everything right away. When they complete a task, they are suddenly laid down from a state of temporary tension to a feeling of utmost relief. Then comes the migraine. It is a purely physiological process. The head and neck muscles, reacting to continuous stress, become overworked. The tightened muscles squeeze the arteries and reduce blood flow. When a person relaxes suddenly, the constricted muscles expand, stretching the walls of the blood-vessel. With every heart beat, the blood being pushed through this vessels expands them further and causes incredible pain.

When a headache strikes, one should stay on one’s feet in the daytime and do simple chores which do not require too much concentration or walk, move around and get some fresh air. The best remedy to prevent headaches is to build up physical resistance through proper nutrition, exercise and constructive thinking. As a first step, the patient should undertake a short fast.


During the fast, citrus fruit juices, diluted with water may be taken six times daily. By taking the load of digestion, the patient will at once save nervous energy which can be utilised for more important purposes. The blood and lymph will also be relieved of a great burden. After a short fast, the diet should be fixed in such a way as to put the least possible strain on the digestion.

Breakfast should consist of fruits, both fresh and dried. Lunch should consist largely of protein foods. Starchy foods such as whole wheat bread, cereals, rice or potatoes should be taken at dinner along with raw salads. Spices, tomatoes, sour buttermilk and oily foodstuffs SHOULD BE AVOIDED!!!. Drinking a glass of water ( warm water in winter and cool water in summer) mixed with a teaspoonful of honey the first thing in the morning, is also a good remedy.

Water Treatment
There are certain water applications which help relieve headaches. Copious drinking of water
can help , as do the cleansing enema with water temperature at 98.6 o F, the hot foot bath, a
cold throat pack, frequent applications of towels wrung out from very hot water to the back of the neck, a cold compress at 40 o to 60o F applied to the head and face or an alternate spinal
compress. Hot fomentations over the abdominal region just before retiring relieve headaches
due to stomach and liver upsets.

Yogic kriyas like jalneti and kunjal, pranayamas like anuloma-viloma, shitali and sitkari and
asanas such as uttanapadasana, sarvangasana, paschimottanasana, halasana and shavasana
are useful in the treatment of headaches.

CONCLUSIONS

DO some fasting (JUICE FAST)
Spices, tomatoes, sour buttermilk and oily foodstuffs SHOULD BE AVOIDED!!!