What are the other Names for this Condition? (Also known as/Synonyms)

• Pancreatic Mixed Acinar-Ductal Carcinoma 

What is Mixed Acinar-Ductal Carcinoma of Pancreas? (Definition/Background Information)

• Mixed Acinar-Ductal Carcinoma of Pancreas is a rare and aggressive type of pancreatic cancer characterized by a mixed population of cells from both acinar and ductal origin within the tumor. For the classification of a cancer to be “mixed”, the tumor should contain at least 25% of each type of cell
• The pancreas, an important organ of the digestive system, can be functionally divided into two parts, exocrine (constituting 95% of the organ) and endocrine. Both these cell types (acinar and ductal origin) belong to the exocrine component of the pancreas
• The frequency of occurrence of Mixed Acinar-Ductal Carcinoma of Pancreas is higher in middle-aged or older individuals belonging to the male gender
• The exact cause of tumor formation is unknown. However, many factors, such as genetics, smoking, exposure to chemicals, and a previous history of cancer are thought to play a role in its development
• Presently, there are no appropriate screening methods for Mixed Acinar-Ductal Carcinoma of Pancreas that can effectively detect the cancer and help improve the overall survival rate, or specific early-warning signs and symptoms
• Mixed Acinar-Ductal Carcinoma of Pancreas can cause complications, such as weight loss, metastasis to liver and peritoneum, gastrointestinal and biliary tract obstruction (causing jaundice), and diabetes (if sufficient numbers of islet cells of pancreas are destroyed)
• The type, location and extent of cancer, as well as the overall health of the affected individual, and his/her response to treatment, may determine the prognosis for Mixed Acinar-Ductal Carcinoma of Pancreas

The pancreas is an important organ of the digestive system.

• Functionally, the pancreas can be divided into 2 parts, namely:
  • Exocrine pancreas, which produces digestive enzymes, and constitute about 95% of this important organ
  • Endocrine pancreas, which secretes hormones such as insulin, glucagon, gastrin, and somatostatin. Insulin and glucagon regulate sugar levels in blood

Pancreatic tumors (benign and malignant) can arise from both the exocrine and the endocrine components of the organ. Most endocrine tumors are benign and develop at a slower rate than exocrine tumors.

• Based on the anatomy of the pancreas, it can be divided into 3 main parts, namely the:
  • Head,
  • Body, and
  • Tail

Pancreatic tumors can affect the head, body, and tail region of the pancreas. Some tumors can affect one region of the pancreas more than the other.

Who gets Mixed Acinar-Ductal Carcinoma of Pancreas? (Age and Sex Distribution)

• Mixed Acinar-Ductal Carcinoma of Pancreas is a very rare type of cancer, reported more frequently in developed countries
• Middle-aged and the older adults are more susceptible to this type of cancer
• Although both genders are susceptible, men are more likely to develop the condition than women
• Mixed Acinar-Ductal Carcinoma of Pancreas is seen to occur in all races and ethnicities

What are the Risk Factors for Mixed Acinar-Ductal Carcinoma of Pancreas? (Predisposing Factors)

The underlying cause of Pancreatic Mixed Acinar-Ductal Carcinoma of Pancreas is unknown at this time, although it is believed that certain factors may increase one’s risk for the condition. These risk factors include:

• Age: Pancreatic Mixed Acinar-Ductal Carcinoma of Pancreas may develop in individuals of all ages, but is seldom diagnosed in individuals, younger than 55 years old
• Smoking: Smoking cigarettes, cigars, or pipes, increases one’s risk due to the damaging effect of chemicals accumulating in the body
• Exposure to toxic chemicals: Exposure to various chemicals can occur due to the nature of one’s occupation, or place of residence. It is believed that being around or associating oneself with certain harmful chemicals may increase the risk
• Gender: Men have a higher risk for developing Mixed Acinar-Ductal Carcinoma of Pancreas than women. This may be attributed to the high rate of male smokers in comparison to female smokers
• Family history: Individuals, with one or more (immediate) family members or relatives with a history of pancreatic cancer, may have an increased risk
• The presence of certain genetic syndromes: Inherited genetic mutations can pass from a parent to their children. Approximately 10% of all pancreatic cancers may be caused by these gene abnormalities, in addition to other health problems. The genetic conditions that may increase the risk for exocrine pancreatic cancers, such as Mixed Acinar-Ductal Carcinoma of Pancreas, may include:
  • Hereditary breast and ovarian cancers, caused by genetic mutations in the BRCA2 gene
  • Familial atypical multiple mole melanoma syndrome, caused by genetic mutations in the p16/CDKN2A gene
  • Familial pancreatitis, caused by genetic mutations in the PRSS1 gene
  • Lynch syndrome, which is usually caused by a genetic defect in the MLH1 or MSH2 gene. Additional changes in other genes such as MLH3, MSH6, TGFBR2, PMS1, and PMS2 may also cause Lynch syndrome
  • Peutz-Jeghers syndrome, caused by genetic defects in the STK11 gene
  • Von Hippel-Lindau syndrome, which occurs owing to genetic mutations in the VHL gene. This syndrome may lead to an increased risk of pancreatic cancer and ampullary carcinoma
• Type II diabetes: Individuals with type II diabetes are thought to have an increased risk of developing any type of pancreatic cancer, including Mixed Acinar-Ductal Carcinoma of Pancreas. This type of diabetes usually begins in early adulthood and is predominately related to obesity
• Chronic pancreatitis: Chronic pancreatitis is characterized as inflammation of the pancreas that does not heal or improve, progressively worsens, and can eventually cause permanent damage. However, it is important to note that most individuals with chronic pancreatitis never develop pancreatic cancer
• Liver cirrhosis: Liver cirrhosis is a condition that is caused by a sudden or continuous damage to the liver tissue. Scar tissue forms in the liver when damage occurs. Individuals with cirrhosis may have an increased risk for developing Pancreatic Mixed Acinar-Ductal Carcinoma 
• Gastrointestinal tract infections: Helicobacter pylori, a bacterium that infects the gastrointestinal tract, may increase the risk for development of Mixed Acinar-Ductal Carcinoma of Pancreas. However, some researchers believe that even excess stomach acid may increase the risk

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Mixed Acinar-Ductal Carcinoma of Pancreas? (Etiology)

The exact cause of Mixed Acinar-Ductal Carcinoma of Pancreas development is not known.

• Research scientists believe that pancreatic cancers of all types, including Mixed Acinar-Ductal Carcinoma of Pancreas, develop primarily due to genetic mutations that leads to tumor formation
• The genetic material ‘DNA’ gives instructions to the cell and directs it to proliferate and/or mature into the type of cell that the body needs at each specific location
• Some individuals may be born with a preexisting abnormality in their DNA that predisposes them to certain types of cancer compared to other individuals in the general population. Some gene mutations that may be associated with Mixed Acinar-Ductal Carcinoma of Pancreas include:
  • KRAS gene - an oncogene, which codes for K-Ras protein that plays a role in regulating cell division
  • TP53 (or p53) gene - plays a role in tumor suppression
  • SMAD4 gene - codes for a protein that functions as a transcription factor that transmits cellular signals (from outside of cells to the nucleus), as well as a tumor suppressor
• However, DNA can be altered or damaged sporadically as well, which causes cells to become malignant (cancerous). DNA damage may trigger the transformation of normal cells into cancerous cells
• Conditions that can cause spontaneous damage to the DNA, resulting in the development of tumors and cancers include:
  • Exposure to certain toxins and poisons, such as some dyes used in tanning hides, industrial chemicals, and cigarette smoke
  • Certain types of bacterial and viral infection

What are the Signs and Symptoms of Mixed Acinar-Ductal Carcinoma of Pancreas?

The signs and symptoms of Mixed Acinar-Ductal Carcinoma of Pancreas depend on a number of factors such as the following:

• Size of the tumor
• Histological type of the tumor
• Whether the tumor is a cyst or a solid mass
• Local spread of the tumor
• Rupture of the cystic mass
• Extent of bleeding within the tumor
• Whether the tumor is present as part of a syndrome, in which case, the signs and symptoms associated with the accompanying syndrome may be noted

Typically, the signs and symptoms of Mixed Acinar-Ductal Carcinoma of Pancreas do not occur until later stages of the cancer development. The type and severity of symptoms may vary among the affected individuals, and the symptoms may include: 

• Anorexia (loss of appetite)
• Jaundice, manifested as yellowing of the skin and white part of the eyes
• Dark urine, also a sign of jaundice
• Pain in the upper part of the abdomen or middle of the back
• Fluid accumulation in the abdomen (ascites), abdominal swelling
• Persistent feeling of abdominal bloating with nausea or vomiting
• Feeling full soon after eating less (having a feeling of satiety after eating less)
• Changes in bowel movements, such as constipation
• Fatty stools
• The formation of blood clots in veins, swelling of legs
• Frequent urination (polyuria), excessive thirst, and blurred vision - all signs of elevated blood sugar levels in the body
• Fatigue, feeling tired easily
• Unintended weight loss
• Depression

Some of the other features of Mixed Acinar-Ductal Carcinoma of Pancreas include:

• The tumor may be present as a single mass or multiple nodules within the organ
• If there is cyst formation, it may occasionally rupture, spilling its contents into the belly
• These tumors are aggressive, meaning that the tumor may spread to local areas

How is Mixed Acinar-Ductal Carcinoma of Pancreas Diagnosed?

Currently, there is no standard diagnostic method to accurately detect Mixed Acinar-Ductal Carcinoma of Pancreas during the early stages. However, healthcare professionals and specialists may sometimes incidentally discover a pancreatic tumor when testing for other conditions.

There are a variety of tests that a healthcare provider may use, to detect, locate, and diagnose Mixed Acinar-Ductal Carcinoma of Pancreas on appearance of the signs and symptoms. These tests and exams include:

• Physical examination and medical history evaluation: Diagnosing pancreatic cancer usually begins with a thorough physical examination and evaluation of complete medical history. During a physical exam, the overall health status and symptoms (such as pain, loss of appetite, and weight loss) of the affected individual are checked
• Computerized tomography (CT) scan of the pancreas: With this radiological procedure, detailed three-dimensional images of structures inside the body are created. CT scans may be also helpful in detecting recurrences, or if Mixed Acinar-Ductal Carcinoma of Pancreas has metastasized to other organs
• Magnetic resonance imaging (MRI) scan of the pancreas: An MRI scan uses magnetic fields that create high-quality pictures of certain body parts, such as tissues, muscles, nerves, and bones. These high-quality images may indicate to a physician if any cancer is present
• In addition, there are certain specific types of MRI scans that can be used in an individual who may have pancreatic cancer. Such radiological procedures include:
  • MR cholangiopancreatography (MRCP): It is a noninvasive test that uses a powerful magnetic field to produce images of soft tissues, bones, organs, and all other internal body structures
  • MR angiography (MRA): It is a noninvasive test that uses a powerful magnetic field to evaluate the blood vessels
• Endoscopic ultrasound (EUS): This is a minimally invasive procedure recommended for individuals who are suspected to have Mixed Acinar-Ductal Carcinoma of Pancreas. An ultrasound device is inserted through a thin tube (called endoscope) down the stomach and into a part of the small intestine. It uses high-frequency sound waves to generate detailed images of the pancreas
• Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used when an individual has developed symptoms of Mixed Acinar-Ductal Carcinoma of Pancreas. An ultrasound device is inserted through a thin tube (called endoscope) down the stomach and into the first part of the small intestine. A dye is injected into the pancreas and bile ducts. The movement of the dye is followed through a series of images. A small tissue sample (biopsy) can be collected during this procedure
• Tissue biopsy: A tissue biopsy of the cyst (including the fluid inside the cyst) or mass is performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a pathologist is considered to be gold standard in arriving at a conclusive diagnosis
  • Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist then decides on additional studies depending on the clinical situation
  • Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, molecular testing, and very rarely, electron microscopic studies, to assist in the diagnosis
• The tissue for diagnosis can be procured in multiple different ways, and they include:
  • Fine needle aspiration (FNA) biopsy of the pancreatic tumor: A FNA biopsy may not be helpful, because one may not be able to visualize the different morphological areas of the tumor. Hence, a FNA biopsy as a diagnostic tool has certain limitations, and an open surgical biopsy is preferred
  • Core biopsy of the pancreatic tumor
  • Open biopsy of the pancreatic tumor
  • Endoscopic retrograde cholangiopancreatography
• Positron emission tomography (PET): A PET scan is a nuclear medicine imaging technique that generates three-dimensional images to show how tissue and organs are functioning. A small amount of radioactive material may be injected into a vein, inhaled or swallowed. A PET scan is also helpful in detecting recurrences, or if any metastasis (to the surrounding lymph nodes of the pancreas) has occurred

A number of blood tests can also be helpful in the diagnosis Mixed Acinar-Ductal Carcinoma of Pancreas or to help determine the treatment options.

• Blood tests for exocrine pancreatic cancers
  • Liver function blood tests
  • Blood tests that may involve tumor markers, such as carcinoembryonic antigen (CEA) and CA 19.9

The diagnostic tests aid in determining the extent of cancer, based on a system of classification, such as the “AJCC system for staging of pancreatic cancer”.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

Determination of type and extent of cancer:

Once a diagnosis of Mixed Acinar-Ductal Carcinoma of Pancreas has been made, the extent to which the tumor has spread is assessed, known as staging. The system used most often to stage pancreatic cancer is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 3 key pieces of information.

The TNM classification for different types of pancreatic cancer, including Mixed Acinar-Ductal Carcinoma of Pancreas, is given below:

Tumor extent (T):

• TX: The main tumor cannot be assessed
• T0: No evidence of a primary tumor
• Tis: Carcinoma in situ (the tumor is confined to the top layers of pancreatic duct cells). (Very few pancreatic tumors are found at this stage.)
• T1: The cancer has not grown outside the pancreas and is 2 centimeters (cm) (about ¾ inch) or less across.
• T2: The cancer has not grown outside the pancreas but is larger than 2 cm across
• T3: The cancer has grown outside the pancreas into nearby surrounding structures but not into major blood vessels or nerves
• T4: The cancer has grown beyond the pancreas into nearby large blood vessels or nerves

Lymph node spread of cancer (N):

• NX: Nearby (regional) lymph nodes cannot be assessed
• N0: The cancer has not spread to nearby lymph nodes
• N1: The cancer has spread to nearby lymph nodes

Distant spread of cancer (M):

• M0: The cancer has not spread to distant lymph nodes (other than those near the pancreas) or to distant organs such as the liver, lungs, brain, etc.
• M1: The cancer has spread to distant lymph nodes or to distant organs

Stage grouping: Once the T, N, and M categories have been assigned, this information is combined to assign an overall stage in a process called stage grouping. The stages identify tumors that have a similar outlook and are treated in a similar way.

Stage 0 (Tis, N0, M0):

• The tumor is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside of the pancreas
• These tumors are sometimes referred to as pancreatic carcinoma in situ or pancreatic intraepithelial neoplasia III (PanIN III)

Stage IA (T1, N0, M0):

• The tumor is confined to the pancreas and is 2 cm across or smaller (T1)
• The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0)

Stage IB (T2, N0, M0):

• The tumor is confined to the pancreas and is larger than 2 cm across (T2)
• The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0)

Stage IIA (T3, N0, M0):

• The tumor is growing outside the pancreas but not into major blood vessels or nerves (T3)
• The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0)

Stage IIB (T1-T3, N1, M0):

• The tumor is either confined to the pancreas or growing outside the pancreas but not into major blood vessels or nerves (T1-T3)
• The cancer has spread to nearby lymph nodes (N1) but not to distant sites (M0)

Stage III (T4, Any, N, M0):

• The tumor is growing outside the pancreas and into nearby major blood vessels or nerves (T4)
• The cancer may or may not have spread to nearby lymph nodes (Any N). It has not spread to distant sites (M0)

Stage IV (Any T, Any N, M1): The cancer has spread to distant sites (M1).

(Source: “The AJCC system for staging pancreatic cancer”; information provided by the American Cancer Society, May 2016)

What are the possible Complications of Mixed Acinar-Ductal Carcinoma of Pancreas?

Complications of Mixed Acinar-Ductal Carcinoma of Pancreas may occur as the cancer progresses, and these may include:

• Jaundice owing to biliary tract obstruction
• Abdominal pain due to tumor growth pressing on the nerves in the abdomen
• Gastrointestinal obstruction
• Diabetes, if the tumor destroys enough islet cells of the pancreas
• Weight loss
• Metastases to the liver and lymph nodes
• Recurrence of Mixed Acinar-Ductal Carcinoma of Pancreas following treatment
• Side effects from the chemotherapy (such as toxicity) and radiation therapy

How is Mixed Acinar-Ductal Carcinoma of Pancreas Treated?

The treatment methods for Mixed Acinar-Ductal Carcinoma of Pancreas are determined by several factors, such as, how advanced the cancer is, the overall health of the affected individual, as well as his/her personal preference(s). The healthcare provider determines and plans the best course of treatment on a case-by-case basis.

Once the extent of cancer has been determined, the following treatment methods may be employed:

• A debulking surgery to reduce the tumor mass (followed by a combination of chemotherapy and radiation therapy may be employed in some instances)
• The debulking procedure helps the chemotherapy treatment in being more effective, since there is lesser tumor mass left for the drugs to act on

Surgery for tumors located in the pancreatic head: Pancreatoduodenectomy

• A surgical procedure that involves the removal of part of the pancreas, part of the small intestine, and the gallbladder
• This procedure is typically used when the tumor is confined to the head of the pancreas
• The technique is also known as a Whipple procedure

Surgery for tumors in the pancreatic tail and body of the pancreas: Distal pancreatectomy

• A surgical procedure that involves the removal of the lower half or tail end of the pancreas
• Post-operative care is important: A minimal physical activity is advised, until the surgical wound heals

After surgical treatment and post-operative care, the attending healthcare professional/specialist may discuss the details of the cancer with the individual. Based on this, further treatment measures may be required that include:

Chemotherapy: It may be administered before or after the debulking procedure, depending on the individual’s specific circumstances.

• Chemotherapy is a treatment that uses drugs to kill cancer cells. In this treatment, a combination of two or more chemotherapy drugs is generally used
• These drugs may be administered orally (by mouth), or intravenously (through a vein in the arm)
• Chemotherapy may be used in addition to radiation therapy (chemoradiation). Chemoradiation is usually used to treat pancreatic cancers that have spread to surrounding organs, but not to distant body regions
• This combination may also be used after surgery to decrease the risk of cancer recurrence

Radiation therapy:

• Radiation therapy attempts to destroy cancer cells by aiming high-energy beams at the cancer cells
• Radiation therapy can be administered either by a machine placed outside the body (external beam radiation), or internally, by a device positioned directly at, or close to the malignant tumor
• This technique may be used before surgery, to decrease the size of a tumor, thus allowing for its easy removal; or after surgery, to kill the remaining cancer cells
• Radiation therapy and chemotherapy are sometimes used as a combination tool

Biological or targeted drug therapy:

• Targeting tumor cells while leaving healthy cells relatively unharmed is the goal of many cancer treatments
• Ongoing scientific research has yielded targeted drug therapy, wherein the unique traits of cancer cells are taken advantage of to destroy those cells

Targeted drug therapy can be effective in many ways, such as:

• Deliver toxic drugs to abnormal cells
• Block pathways that cancer cells use to proliferate without control
• Stop blood supply to actively dividing cancer cells
• Activate the immune system to fight and destroy cancer cells: Living organisms or products from living organisms may be suitably modified and used to initiate an immune response to specifically attack and destroy cancer cells
• Alter the cancer cells to trigger their cell death mechanism

The advantages of targeted therapy over conventional chemotherapy are:

• Increased concentration of medication delivered to specific target cells
• Prolonged interaction of medication with abnormal cells for effective destruction of such cells
• Decreased effect on healthy cells
• Possibly fewer side effects

One type of targeted drug therapy approved for treatment of pancreatic cancer is Erlotinib. Erlotinib is designed to disrupt the epidermal growth factor receptor (EGFR) protein on cancerous cells (located on the exterior of a cell), to arrest cell division. The drug is orally (in pill-form) administered to individuals and usually taken in combination with chemotherapy.

Follow-up care with regular screening and check-ups are important, to monitor the status of the tumor.

How can Mixed Acinar-Ductal Carcinoma of Pancreas be Prevented?

The US Preventive Services Task Force (USPSTF) currently does not have any recommendation for screening Mixed Acinar-Ductal Carcinoma of Pancreas for the general population. However, taking steps to modify certain behavioral/lifestyle choices may help decrease its risk. These measures include:

• Smoking cessation: Smoking is the most significant risk factor associated with all types of pancreatic cancer. 20% to 30% of all pancreatic cancers develop due to smoking
• Physical activity: Obesity increases the risk for pancreatic cancers due to increased levels of inflammation in the body, which negatively impacts the overall immunity. Individuals, who participate in a modest amount of physical activity, may decrease their risk
• Adequate consumption of fruits and vegetables: A healthy diet, low in saturated fats and rich in many fruits and vegetables, may help decrease one’s risk for pancreatic cancer

Due to the metastasizing potential and chances of recurrence of Mixed Acinar-Ductal Carcinoma of Pancreas, regular medical screening at periodic intervals with blood tests, radiological scans, and physical examinations are often needed, once an individual is diagnosed with the cancer.

What is the Prognosis of Mixed Acinar-Ductal Carcinoma of Pancreas? (Outcomes/Resolutions)

The prognosis of Mixed Acinar-Ductal Carcinoma of Pancreas depends upon a set of several factors, including:

• Stage of tumor: With lower-stage tumors, when the tumor is confined to site of origin, the prognosis is usually excellent with appropriate therapy. In higher-stage tumors, such as tumors with metastasis, the prognosis is poor
• The surgical resectability of the tumor (meaning, if the tumor can be removed completely)
• Overall health of the individual: Individuals with overall excellent health have better prognosis compared with those with poor health
• Age of the individual: Older individuals generally have poorer prognosis than younger individuals
• Whether the tumor is occurring for the first time, or is a recurrent tumor. Recurring tumors have worse prognosis 
• Response to treatment: Tumors that respond to treatment have better prognosis compared to tumors that do not respond to treatment

The overall 5-year survival rate of individuals with exocrine pancreatic cancer, such as Mixed Acinar-Ductal Carcinoma of Pancreas, is generally poor, even during the initial stages of the cancer. In majority of cases, surgery to remove the tumor is not an option due to the cancer spreading to other parts of the body.

Additional and Relevant Useful Information for Mixed Acinar-Ductal Carcinoma of Pancreas:

• It is estimated that the average lifetime risk of developing pancreatic cancer is about 1 in 67 (1.5%)
• Individuals can reduce their risk of developing pancreatic cancer through lifestyle or behavioral changes
• Several clinical trials are ongoing or scheduled for targeted drug therapy. Information may be found on www.clinicaltrials.gov