Pancreatic adenocarcinoma - prognosis for the tumor and methods for its elimination

• What types of cancer can occur in the head of the pancreas?
• Stages of pancreatic head cancer
• Risk factors
• Symptoms of pancreatic head cancer
• Diagnostic methods. Screening
• Treatment of pancreatic head cancer
• Prognosis and survival

The pancreas is approximately 15 cm long and anatomically consists of three parts: head, body and tail. The head is located in the upper right part of the abdomen, at the level of the first two lumbar vertebrae. It is covered by the duodenum.

The main function of the pancreas is to produce digestive enzymes. The duct of the gland emerges from its head, then connects with duct - the main bile duct - and together they flow into the duodenum.

In addition, the pancreas contains endocrine cells that produce hormones. The most famous of them is insulin.

What is pancreatic adenocarcinoma

This is a malignant neoplasm located in the tissues of the pancreas (PG).

The tumor can have different sizes and differs:

1. Long-term, asymptomatic course.
2. Difficulty visualization.
3. High probability of metastases.
4. The rapid course of the process and the involvement of new tissues in it.

The pancreas is located in close proximity to the intestines, liver, and stomach. This organ is surrounded by large lymph nodes. This “neighborhood” leads to rapid progress; through large lymph nodes, metastases affect the intestines, liver, and stomach.

Damage to the pancreas and the development of atypical cells in it are difficult to diagnose, even in case of timely treatment. The reason is that the organ can be fully visualized only during specific examinations.

Regular ultrasound will not bring the desired result; detecting small tumors is unlikely to help.

Adenocarcinoma or exocrine cancer is widespread and is diagnosed in most patients with such a diagnosis. Endocrine cancer is less common and involves the tumor growing from hormone-producing cells.

Description of the disease

Of the 19 morphological variants of pancreatic tumors, every third has a completely or partially adenocarcinoma structure. Of all malignant diseases, pancreatic cancer accounts for just over 3%.

In Russia, almost 16 thousand primary patients are identified annually, that is, 12 out of every 100 thousand. Mostly mature citizens are affected, and in women, cancer occurs on average 6 years later - after the 70th birthday. The lowest incidence is among Cypriots; carcinoma most often affects Hungarians and Finnish women.

Causes

There are various factors that contribute to the development of oncology; if we talk about pancreatic cancer, the reasons for its occurrence have not yet been established. Doctors identify several factors that can provoke cancer, including:

• Smoking, a bad habit, can have a detrimental effect not only on the functioning of the lungs, but also on other organs, including the lifespan;
• unfavorable living conditions, poor ecology in the region, high mortality from cancer, etc.;
• long-term diabetes mellitus, with lack of corrective therapy, medications;
• the patient has a history of chronic pancreatitis or liver disease;
• hereditary predisposition to the disease, the presence of deaths from cancer among relatives;
• obesity, metabolic disorders in the body, some genetic abnormalities.

Poor nutrition, bad habits and a sedentary lifestyle all aggravate the situation. However, as well as the presence of chronic diseases: inflammation of the pancreas, gastric ulcer.

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How does heredity affect

It is believed that oncology is not inherited. Only a predisposition to it, and then only if there are several relatives in the family with a similar diagnosis.

People with a hereditary predisposition to tumor formations of the pancreas are recommended to see an oncologist once every 8-12 months.

Such patients are not registered, despite the high risks of developing cancer, but they are advised not to neglect scheduled visits to the doctor. Since such “prevention” will help to significantly reduce risks or diagnose a tumor in a timely manner.

If there is a genetic predisposition to cancer, or a combination of unfavorable factors, the chances of developing a malignant neoplasm increase.

Treatment options

All adenocarcinomas of the gland can be divided into three large groups:

• operable from stages 1 to 3;
• doubtfully operable ;
• inoperable stage 4 and functionally not subject to surgery due to the severity of the patient’s condition.

However, it is a rare patient suffering from pancreatic cancer who never ends up on the operating table during the course of their illness. An operable tumor must be removed at the first stage; a non-removable tumor will require intervention to create a bypass of the bile ducts, or require unloading surgery for jaundice.

For adenocarcinoma of the head of the gland, an extensive and technically complex gastropancreaticoduodenal resection is performed; laparoscopic access is not excluded and is no worse than the classic one with dissection of the abdominal wall.

For adenocarcinoma of the body or tail, the affected parts of the organ and the spleen are removed, and the intervention is called “distal subtotal resection.”

In case of a conglomerate involving all parts of the gland, they resort to complete removal of the organ - pancreatectomy.

After radical surgery for stages 1-3, preventive chemotherapy is prescribed for six months, which is better to start in the next month and a half and no later than 3 months.

If operability is questionable, several courses of chemotherapy are given before surgery; if there is no change for the worse, then surgery is prescribed. Preventative - adjuvant chemotherapy should be six months along with preoperative chemotherapy.

With an initially inoperable stage 3 process, chemotherapy is carried out for several months, which can be aggravated by radiation; if everything goes well, then one can hope for radical surgery. If surgery remains unavailable after chemoradiotherapy, maintenance chemotherapy is prescribed for six months. Of all the morphological variants, only adenocarcinoma is the most sensitive to cytostatics, but the result leaves much to be desired.

In the metastatic stage, multicomponent chemotherapy is performed; treatment options are limited only by the patient's condition.

Symptoms of adenocarcinoma

It is noteworthy that the disease, although so severe, can be asymptomatic for a long period. This is a feature of cancer that makes diagnosis difficult and leads to complications.

If atypical cells appear in the pancreas, then at various stages of tumor development, a person may be bothered by the following symptoms:

1. Pain that occurs after eating or without eating.
2. Discomfortable sensations in the right side, in the liver area, change in skin color.
3. Belching that occurs after eating, not accompanied by a food taste or bitterness.
4. Quick satiety with food, feeling of fullness even with a minimum serving size.
5. Belching with bitterness, metallic taste, discomfort before or after eating.
6. Frequent attacks of vomiting, nausea, problems with stool.

The patient may be bothered by various symptoms, ranging from mild indigestion to serious, paroxysmal pain in the right side. There are other signs that indicate the presence of cancer:

• general deterioration of health with a significant decrease in performance;
• weight loss, with normal nutrition, change in color of the skin of the face or body.

Oncologists note that people with pancreatic cancer experience yellowing of the skin. This occurs due to an increase in the concentration of bilirubin in the blood. But such a manifestation may also indicate that a person has liver problems. Observed in hepatitis.

Due to the disappointing prognosis of pancreatic adenocarcinoma, it is worth paying attention to minimal changes in the body, as they may indicate oncology.

Symptoms and signs of pancreatic cancer

The first signs of the disease often do not appear immediately - most of them appear only after the tumor grows to a large size.

Once it becomes large enough, or its cells spread to other tissues, a person will experience the following symptoms:

• Pain.
  The growing mass puts pressure on nerves and other organs, clogs the digestive tract and causes pain in the abdomen or back.
• Darkening of urine.
  Our body has a special liquid - bile, which is necessary for digesting food, which is produced by the liver. It is stored in the gallbladder, from there it passes into the intestines and is excreted in the feces. When cancer grows and blocks its excretory duct, too much bilirubin, a red-yellow pigment, accumulates in the body. Its excess enters the urine and turns it brown.
• Weight loss.
  Pancreatic cancer often deprives a person of appetite, which ultimately leads to weight loss. In addition, some types of dangerous tumors produce hormones. Hormones are substances that are created by our glands, enter various organs through the bloodstream and tell them how to act - to work or rest, to secrete something or absorb something. , making it difficult to absorb nutrients from foods, and a person loses weight, even if he follows a normal diet.
• Jaundice.
  The skin and whites of the eyes turn yellow due to blockage of the bile duct and the accumulation of bilirubin in the body, which stains them.
• Nausea and vomiting.
  Unpleasant sensations occur if the tumor affects substances involved in digestion, increases the amount of acid in the stomach, or blocks the release of partially digested contents into the intestines.
• Excessive hunger or thirst.
  These symptoms are signs of diabetes, a disease in which the body does not produce enough insulin to control blood sugar levels. They occur after cancer destroys the cells that produce this essential substance.
• Itching.
  Itching and irritation often develop due to the accumulation of excess bilirubin in the skin.
• Red blistering rash.
  Develops with glucagonoma, a tumor of the pancreas that leads to the production of excessive amounts of the hormone glucagon.
• Enlarged gallbladder.
  If the bile duct is blocked by a tumor, the flow of bile from it is disrupted, and the bladder enlarges, after which pain appears in the abdominal area.
• Light or greasy stools.
  The tumor disrupts the functioning of the pancreas and the release of enzymes, making fat difficult and incompletely digested. It ends up in the stool, which looks greasy and doesn't sink - it floats. The color of stool is affected by bilirubin - the less it is, the lighter the waste products.
• Diarrhea.
  It occurs in various types of pancreatic cancer and can be a sign of a tumor with an unusual name - VIPoma. It secretes a special substance that sends too much water into our gastrointestinal tract, the excess of which causes severe watery diarrhea. In addition, cancer often interferes with the proper absorption of what is eaten, which leads to digestive problems and diarrhea.
• Swelling, redness and pain in the leg.
  All these are signs of thrombosis, that is, the presence of blood clots in the vessels of the legs. Often these signs become the first dangerous symptoms of pancreatic cancer. If such a formation breaks away from the wall of the vein and enters the lung, a person experiences thromboembolism - blockage of the pulmonary artery.
• Weakness, confusion, sweating and rapid heartbeat.
  Such symptoms are caused by insulinomas - tumors that produce insulin, the excess of which leads to a decrease in blood sugar levels. A strong drop in its level can lead to fainting or coma - a condition in which a person loses consciousness and vital body functions are disrupted.

Types and degrees

When carrying out diagnostic procedures, the stage of cancer is determined, and such measures make it possible to select treatment for the patient.

Let's consider the main stages of the development of the disease:

Classification by type:

Classification

In the in situ stage - stage 0, the disease is almost undetectable.

Stage 1 - a tumor in the gland no more than 4 cm and, of course, without any metastases, even in regional lymph nodes.

Stage 2 involves two interpretations: a tumor of more than 4 cm with lymph nodes clear of malignant cells and a smaller volume, but with cancer screenings in the regional lymph collector.

Stage 3 - the tumor conglomerate involves large vessels and nerves passing nearby.

Stage 4 - distant metastases from any primary tumor.

Diagnosis of adenocarcinoma

Carrying out differentiated diagnostics when making such a complex diagnosis as cancer is necessary. The problem is that standard procedures may not help detect the tumor because the organ is difficult to completely visualize.

What is done as part of the diagnosis:

1. CT or MRI of the organ, since such examinations are the most informative.
2. Ultrasound is done, but only in conjunction with other studies.
3. You will need to donate blood for tumor markers to determine the presence of the CA 19-9 enzyme in the blood.
4. Blood is taken for biochemical analysis to determine the level of bilirubin in the serum.
5. Laparoscopy is prescribed, which allows you to examine the organ and collect information about its condition.
6. Often, a biopsy, histology, and other procedures are performed to clarify the diagnosis, exclude or confirm cancer.

Previously, it was believed that the presence of CA 19-9 enzymes in the blood indicates oncology. But the increase may not be associated with a malignant tumor of the pancreas. To make an accurate diagnosis, a number of additional examinations will be required.

Treatment of pancreatic adenocarcinoma

Radiation therapy is carried out immediately after surgery; in combination, methods can achieve the best results. And also eliminate the possibility of relapse of the disease.

Removal of the pancreas

There are three methods that can rid a person of a tumor:

Symptoms

Symptoms of cancer at an early stage are not obvious and non-specific; in most cases - in almost 60% - pancreatic adenocarcinoma is detected in an advanced stage with distant metastases. Only every fifth tumor is diagnosed in stages 1-2, slightly less - with stage 3. Clinical manifestations indicate a fairly large size of the cancerous node, involving nearby anatomical structures.

The most common symptom is pain in eight out of ten. It is believed that cancer of the head of the gland causes pain on the right side under the ribs; damage to the body will result in pain in the left hypochondrium. In life, such a clear differentiation of pain syndrome does not happen, but the connection between pain and food and alcohol and its high intensity are characteristic, since it is caused by the involvement of nerve trunks and plexuses.

Compression of the bile duct will manifest as obstructive jaundice with progressive deterioration, painful itching and vomiting with constant nausea.

For those suffering from pancreatic pathology, reduced weight is typical.

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Complications, metastasis

Metastases can cause damage to nearby organs: stomach, liver, gallbladder.

Doctors note the following problems as possible complications:

Complications include relapse of cancer. Cancer can return even after proper treatment.

Pancreatic cancer (malignant tumor of the pancreas) is most often seen in people over 60 years of age. If the diagnosis is made at an early stage, then surgery to remove the tumor offers a chance of recovery. In general, the more advanced the stage of cancer (tumor size and extent), the less likely it is that treatment will lead to cure. However, treatment can often slow the progression of cancer.

What is the pancreas?

The pancreas is located in the upper abdomen and lies behind the stomach and intestines. The pancreas is shaped like a tadpole, so it has a head, a body and a tail. The part that lies closest to the duodenum is called the head (the part of the intestine immediately after the stomach). The pancreas produces a fluid that contains enzymes (chemicals) needed for digestion. Enzymes are produced by pancreatic cells and enter thin ducts (tubes). The ducts join together like the branches of a tree to form the main pancreatic duct. It carries enzyme-rich fluid into the duodenum. Enzymes in the pancreas are in an inactive form (otherwise they would digest the gland itself). They are activated in the duodenum to digest food. throughout the pancreas are groups of specific cells called islets of Langerhans. These cells produce the hormones insulin and glucagon. Hormones are released (secreted) directly into the bloodstream and control blood sugar levels. The bile duct carries bile from the liver and gallbladder. It joins the pancreatic duct just before it opens into the duodenum. Bile also enters the duodenum and is involved in the digestion of food.

What is cancer?

Cancer is a disease of the body's cells. The body is made up of millions of tiny cells. There are many types of cells in the body, and there are many types of cancer that originate from different types of cells. What all types of cancer is that all cancer cells are abnormal and capable of dividing uncontrollably. A malignant tumor is a tissue growth consisting of cancer cells that continue to divide. Malignant tumors invade neighboring tissues, causing damage. Malignant tumors can also spread to other parts of the body. This occurs when some cells break away from the primary tumor and are carried by the bloodstream or lymph to other parts of the body. These small groups of cells can grow and form secondary tumors (metastases) in one or more organs. These secondary tumors can also grow, invade and damage nearby tissue, and spread again.

Some types of tumors are more serious than others, some are easier to treat than others (especially if diagnosed early), and some have a better prognosis than others. Thus, cancer is not one disease. In each case, it is important to know exactly what type of cancer is developing, how big the tumor is and how widespread it is. This will give you reliable information about treatment options and prognosis.

What is pancreatic cancer?

Pancreatic cancer is a relatively rare disease. For example, in the UK it develops in about 1 in 10,000 people per year. There are several types of pancreatic cancer , but in 9 out of 10 cases it is ductal adenocarcinoma.

Ductal adenocarcinoma of the pancreas

This type of cancer develops from malignant cells of the pancreatic duct. They divide and a tumor develops in and around the duct. As the tumor :

· It may block the bile duct or main pancreatic duct. This stops the flow of bile and/or pancreatic juice into the duodenum.

· The tumor grows deep into the pancreas . One day it may pass through the wall of the pancreas and grow into neighboring organs such as the duodenum, stomach or liver.

· Some cells may enter the lymphatic ducts or bloodstream. Thus, the tumor can spread to nearby lymph nodes or other areas of the body (metastasize).

·

Other types of pancreatic cancer

There are several rare types of cancer that originate from other types of pancreatic . For example, pancreatic cells that produce insulin or glucagon can become malignant (insulinomas and glucagonomas). They behave differently than ductal adenocarcinoma. For example, they may produce too much insulin or glucagon, which can cause various symptoms. The remainder of this article discusses only pancreatic .

What causes pancreatic cancer (pancreatic adenocarcinoma)?

A cancerous tumor starts as an abnormal cell. The exact reason why a cell becomes cancerous is unclear. Something is thought to damage certain genes in the cell. This makes the cell abnormal and leads to uncontrolled division.

Many people develop pancreatic cancer However, there are some risk factors that increase your chance of developing pancreatic cancer . Namely:

· Aging. It is more common in older people. Most cases occur in people over 60 years of age.

· Smoking.

· Diet. A diet rich in fat and meat increases the risk.

· Obesity.

· Chronic pancreatitis (persistent inflammation of the pancreas ). In most cases, chronic pancreatitis occurs due to alcohol abuse. There are other more rare causes.

· Diabetes. Note : Diabetes is common and the vast majority of people with diabetes do not develop pancreatic cancer .

· Chemical substances. Exposure to some pesticides, dyes, and chemicals used in metal cleaning increases the risk.

· Jaundice

Genetic and hereditary factors

Most cases of pancreatic cancer are not familial. However, some families have a higher than average of pancreatic cancer It is believed that about 1 in 10 cases of pancreatic cancer are caused by an inherited gene abnormality. pancreatic cancer runs in your family , talk to your doctor. You may be offered screening tests to detect pancreatic cancer at an early stage, when there is a high chance of cure. A research group from the University of Liverpool, called the European Registry of Hereditary Pancreatic Cancer and Hereditary Pancreatitis (EUROPAC), is investigating the causes of pancreatic cancer . pancreatic cancer screening in high-risk individuals.

What are the symptoms of pancreatic cancer?

Symptoms of bile duct blockage

In about 7 out of 10 cases, the tumor develops in the head of the pancreas . Small tumors are initially asymptomatic. As the tumor , it begins to block the bile ducts. This stops the flow of bile into the duodenum, which leads to:

· Jaundice ( yellow coloration of the skin due to the entry of bile into the bloodstream due to a blockage).

· Darkening of urine - caused by the kidneys filtering blood with a high content of bile acids.

· Pale feces - because bile does not enter the feces, causing their normal brown color.

· Generalized itching caused by bile entering the bloodstream.

Pain is often not the first sign. Therefore, painless jaundice is often the first symptom of pancreatic cancer . Nausea and vomiting are also rare symptoms .

Other symptoms

As the tumor in the pancreas symptoms may appear :

· Pain in the upper abdomen. The pain may also radiate to the back.

· General poor health and weight loss. These symptoms often appear first when cancer develops in the body or tail of the pancreas (when the bile duct is not blocked).

· Poor digestion of food, as the amount of pancreatic juice may decrease. This can lead to foul-smelling, pale feces and weight loss.

· In rare cases, when almost the entire gland is affected by a tumor , diabetes develops.

· In rare cases, a tumor can trigger inflammation in the gland - acute pancreatitis. This can cause severe abdominal pain.

If the cancer spreads to other parts of the body, a variety of other symptoms may develop.

How is pancreatic cancer diagnosed and evaluated?

Initial assessment

There are many causes of jaundice and the other symptoms listed above. For example, a blocking gallstone or hepatitis (inflammation of the liver). Therefore, if you have jaundice or other symptoms mentioned above, do some basic tests. This usually involves an ultrasound scan of the abdomen and some blood tests. These basic tests can usually give a good clue if the jaundice is caused by a block in the head of the pancreas .

Estimation of volume and prevalence

If pancreatic cancer or is highly probable from basic tests, then the following studies should be carried out to assess the prevalence. For example:

· CT (computed tomography) scan is a common test used to evaluate pancreatic cancer . This is a special x-ray examination that can give a fairly accurate picture of the internal organs.

· Sometimes an MRI is performed. MRI produces images using magnetic resonance. MRI uses a powerful magnetic field and radio waves to create computer-generated images of tissues, organs and other structures in the body.

· Endoscopic ultrasound examination (endo-ultrasound). An endoscope (gastroscope) is a thin, flexible telescope. It is administered through the mouth, esophagus and stomach and into the duodenum. An endoscope contains fiber optic channels that transmit light so doctors or nurses can see what's going on inside. Some endoscopes have miniature ultrasound scanners on the end to provide images of structures located behind the intestine, such as the pancreas .

· Chest X-ray.

· Laparoscopy . This is a procedure to look into the abdominal cavity using a laparoscope . A laparoscope looks like a thin telescope with a light source. It is used to illuminate and magnify images of abdominal structures. The laparoscope is inserted into the abdomen through a small incision in the skin.

Separate tabs/links provide more detailed descriptions of each procedure. cancer staging . The objectives of staging are to search for:

· How much the pancreatic tumor , and whether it has partially or completely invaded the wall of the pancreas .

· Has the cancer spread to local lymph nodes?

· Whether the cancer to other organs (metastasis).

Determining the stage of cancer helps your doctor determine the best treatment options. It also provides reasonable data on the prospects (forecast). More detailed information is provided in the separate tab/link cancer .

Biopsy

A biopsy is the removal of a small sample of tissue from some part of the body. The sample is then examined under a microscope to look for abnormal cells. If a biopsy is necessary, one way to obtain pancreatic is to obtain a tissue sample during an endoscopy. This is done by passing a small grasping instrument through the side channel of the endoscope (gastroscope). Or sometimes a biopsy can be done at the same time as the scan. The wait for biopsy results may take up to two weeks.

What are the treatment options for pancreatic cancer?

Possible treatment include surgery , chemotherapy , and radiotherapy. Treatment in each case depends on various factors, such as the stage of the cancer (the size of the cancer and how far it has spread) and your overall health.

It is necessary to discuss this with a specialist who knows your case. He or she will be able to give you the pros and cons, likely success rate, possible side effects, and other details about possible treatment for your type of cancer . It is also necessary to discuss treatment . For example:

· The goal of treatment may be to cure the cancer . Some types of pancreatic cancer can be cured if treated in the early stages of the disease. (Doctors prefer to use the word "remission" rather than "cure." Remission means that after treatment there are no signs of cancer. If you are in remission, you may be cured. However, in some cases, cancer may take months or years to return later, which is why doctors sometimes avoid using the word “cure.”)

· The goal of treatment may be to control the cancer . If a cure is not realistic, treatment can often limit the growth or spread of the tumor to slow progression. This may relieve symptoms for a while.

· The goal of treatment may be to relieve symptoms . If cure is not possible, treatment may be given to shrink the tumor , which may relieve symptoms such as pain. If the cancer is advanced, treatment as nutritional supplements, analgesics, or other medications may be needed to relieve pain and other symptoms .

·

Surgical treatment

If the cancer is at an early stage, then there is a small chance that surgery will lead to a cure . (Early stage means a small tumor that does not extend beyond the pancreas and has not spread to the lymph nodes or other areas of the body).

· If the tumor is located in the head of the pancreas , then surgery to remove the head is possible. This is a long and complex operation , since the surrounding structures such as the duodenum, stomach, bile duct, etc. must be reconstructed after removal of the head of the pancreas.

· If the tumor is located in the body or tail of the pancreas , then in some cases it is possible to remove the affected areas.

The reason the probability is low is that in many cases it is believed that the stage is early, but some cells have already spread to other parts of the body but cannot yet be detected by scanning or other testing methods. Over time, secondary tumors .

If the cancer is at an advanced stage, surgery cannot cure the disease. surgical may be used to relieve symptoms . For example, jaundice caused by a blocked bile duct can be reduced. Bypass and stenting of the bile duct can be used. (A stent is a small, rigid tube made of plastic or metal designed to keep a duct or channel open. Typically inserted with an instrument attached to an endoscope.)

Related discussions

Chemotherapy

Chemotherapy is a method of treating cancer with anticancer drugs that destroy cancer cells or stop them from dividing. If chemotherapy is used in addition to surgery, it is called adjuvant chemotherapy . For example, after surgery a course of chemotherapy . It is needed to destroy cancer cells that may have spread beyond the primary tumor .

Radiation therapy

Radiation therapy is a treatment that uses high-energy beams of radiation that are focused on tissue affected by cancer . This kills cancer cells or stops them from dividing. Radiotherapy is rarely used in the treatment of pancreatic cancer .

What is the prognosis (prospect)?

If pancreatic cancer is diagnosed and treated early, there is a small chance that surgery will be curative. Generally, the smaller the tumor and the earlier the tumor , the better the prognosis . Some tumors developing in the head of the pancreas are diagnosed very early, as they block the bile duct and jaundice . This symptom leads to research, which leads to surgery , which leads to cure for small tumors .

However, most cases of pancreatic cancer progress over a long period of time before symptoms and a diagnosis is made. In most cases, a cure is unlikely. However, treatment can slow the progression of cancer .

Cancer treatment is an evolving field of medicine. The development of new treatments , so information about prognosis is very general. The specialist who deals with a particular case can provide more accurate information regarding an individual's prognosis , as well as whether a certain type and stage of cancer therapy .

Diet

To maintain weight and eliminate vomiting and nausea, patients are advised to adhere to the following dietary rules:

• exclude unhealthy foods, fatty and fried foods from the diet;
• Alcohol is prohibited.

Patients are not recommended to overeat; they should eat in small portions, 6-8 times a day. Drink 6 glasses of water every morning.