Chronic Pancreatitis to Pancreatic Cancer

Albert B. Lowenfels, MD

Disclosures

December 17, 2015

Chronic pancreatitis and pancreatic cancer are two of the major diseases affecting the pancreas. Both are serious disorders for which current therapy has not been proven to be effective.

Physicians have known for more than 20 years that some patients with chronic pancreatitis eventually develop pancreatic cancer. However, it is an uncommon event: Over two decades, only about 4% of patients with well-documented chronic pancreatitis will develop pancreatic cancer.[1] Patients who experience only a single attack of acute pancreatitis without developing recurrent pancreatitis or chronic pancreatitis do not progress to pancreatic cancer.

The symptoms of chronic pancreatitis can be easily confused with those of pancreatic cancer, leading to diagnostic uncertainty. In addition, so-called "type 3c diabetes" can be a complication in patients with either chronic pancreatitis or pancreatic cancer.

At the 46th Annual Meeting of the American Pancreatic Association, a mini-symposium was dedicated to discussing chronic pancreatitis, pancreatic cancer, and diabetes.

Type 3c Diabetes

Dana K. Andersen, MD, opened the symposium by defining and discussing type 3c diabetes and listing causative factors. In the United States and Europe, 5%-8% of all diabetes is this type of disease. The frequency is higher in Asia and India. About 20%-30% of patients with chronic pancreatitis have "pancreatogenic" diabetes, and the frequency increases with the duration of pancreatitis. More than one half of patients with long-standing chronic pancreatitis will require insulin.

Why does diabetes develop in these patients? One explanation is that inflammation and resulting fibrosis lead to a loss of islet cells. A second reason is extirpation of the islet cells as a result of surgical treatment.

Inhibition of islet cell function as a result of pancreatic disease is yet another reason. In this form of diabetes, hypoglycemia is common and insulin levels are low.

Diagnosis of type 3c diabetes is based on a documented history of pancreatic disease, evidence of exocrine insufficiency, and ruling out type 1 and type 2 diabetes. Having type 3c diabetes is associated with a 33-fold increased risk for pancreatic cancer—an enormous increase.[2]

Diabetes and Pancreatic Cancer

Suresh Chari, MD, continued the discussion of diabetes and pancreatic disorders, focusing on the relationship between diabetes and pancreatic cancer. He pointed out that they have common risk factors, such as obesity and insulin resistance, perhaps because they share common genetic factors. Patients with type 2 diabetes without underlying pancreatitis have an almost twofold excess risk for pancreatic cancer. The risk is not as high as with type 3c diabetes, but it still constitutes a major risk factor for pancreatic cancer.[3]

Dr Chari presented several slides demonstrating changes in the pancreas of diabetic patients. These included decreased volume, increased fibrosis, and acinar atrophy. Diabetic patients have significantly reduced levels of fecal elastase 1, a marker of pancreatic insufficiency, compared with control subjects.

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