Pancreatic Cancer: Case and Discussion - PowerPoint Presentation

Slide1

Pancreatic Cancer: Case and Discussion

Andrew D. Rhim, MD

University of Michigan

Medical School

Slide2

Clinical Case

72yo man presents to General GI clinic for abdominal discomfort after eating

Developed over the past 8-9 months

Vague, dull discomfort/pressure starting 10-20 minutes after eating and lasting for 30min to a few hours

Does not interfere with daily activities (2-3/10)

Located in the

epigastrum

, MAYBE radiating to his back

Not eating helps, though he has been careful to maintain caloric intake

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HPI

72yo man presents to General GI clinic for abdominal discomfort after eating

No associated nausea, vomiting, diarrhea or constipation

Has noted 20lb weight loss in the past 2-3 months, though he denies anorexia

Denies new-onset depression, jaundice, malaise

Has noted increased urination and thirst (maybe)

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Review of Systems

Constitutional: Positive for unexpected weight change. Negative for fever, chills, diaphoresis, activity change, appetite change and fatigue.

HENT: Negative.

Eyes: Negative.

Respiratory: Positive for apnea and cough. Negative for choking, chest tightness, shortness of breath, wheezing and stridor.

Cardiovascular: Negative.

Gastrointestinal: Positive for abdominal pain. Negative for nausea, vomiting, diarrhea, constipation, blood in stool, abdominal distention, anal bleeding and rectal pain.

Endocrine: Negative.

Genitourinary: Negative.

Musculoskeletal: Negative.

Skin: Negative.

Allergic/Immunologic: Negative.

Neurological: Negative.

Hematological: Negative.

Psychiatric/Behavioral: Negative.

(No depression)

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Past Medical History

History of colon cancer 10 years ago, in remission after colectomy.

GERD

HTN

COPD (previous smoker)

Cataracts

Diabetes mellitus II

Diagnosed 6 months ago

Recent requirement of insulin 2 weeks ago

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Social History

Previous smoker—quit 2011

EtOH

—4 cans a week, denies history of binging

No IVDA

Married with 3 grown children

Retired school teacher

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Family history

Colon cancer in father (60)

Unknown cancer in mother, sister, maternal aunt, maternal uncle.

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Physical Exam

Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.

HENT:

Normal

Head:

Normocephalic

and

atraumatic

.

Nose: Nose normal.

Mouth/Throat: No

oropharyngeal

exudate.

Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.

Neck: Neck supple. No tracheal deviation present.

Cardiovascular: Intact distal pulses.

Pulmonary/Chest: Effort normal and breath sounds normal. No stridor. No respiratory distress. He has no wheezes.

Abdominal: Soft.

Nl

bowel sounds. He

exhibits no

distention

. There is no guarding.

Musculoskeletal

: Normal range of motion. He exhibits no edema.

Neurological

: He is alert and oriented to person, place, and time. No cranial nerve deficit. Coordination normal.

Skin: Skin is warm and dry. No rash noted. He is not diaphoretic. No erythema. No

pallor or jaundice

Psychiatric

: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.

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Labs

144

4.3

98

30

10

0.98

241

1.0

31.5

4.4

14.8

365

ALT = 37

AST = 36

TBili

=

1.6

Alk

Phos

= 99

Alb

= 4.1

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CT abdomen/pelvis

Pancreas:

Atrophy of body and tail of pancreas

Dilated main pancreatic duct with transition point, with no obvious mass lesion

Remainder of the pancreas appears normal

No lymph node enlargement or other masses.

Exam otherwise normal

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Next steps?

Repeat cross sectional imaging (MRCP)

Endoscopic ultrasound +/- FNA

EGD + colonoscopy

Treat patient for IBS

Pancreatic enzyme supplementation

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Next steps?

Repeat cross sectional imaging (MRCP)

Endoscopic ultrasound +/- FNA

EGD + colonoscopy

Treat patient for IBS

Pancreatic enzyme supplementation

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Why? High suspicion for neoplasm

HPI:

Vague

, dull discomfort/pressure

starting 10-20 minutes after eating and lasting for 30min to a few hours

Located

in the

epigastrum

, MAYBE radiating to his back

Has noted

20lb

weight loss

in the past 2-3 months, though he denies anorexia

Denies new-onset depression, jaundice, malaise

Has noted

increased urination and thirst

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Why? High suspicion for neoplasm

PMH

Diabetes mellitus II

Diagnosed 6 months ago

Recent requirement of insulin 2 weeks ago

Labs:

Fasting glucose

elevated

CT pancreas:

Abrupt cut-off of pancreatic duct

Atrophy of distal pancreas

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Mass in body of pancreas

Diagnosis:

Pancreatic ductal adenocarcinoma,

Stage 1

Treatment:

Surgical resection +

Adjuvant chemo

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Pancreatic Cancer Epidemiology

Incidence: 11.7 per 100,000

Rising incidence

6.7% increase 1995

2005

Lifetime risk: 1.41%

1 in 71 Americans will be diagnosed w/ PC

Median age of diagnosis: 72

Median age of death: 73

SEER, 2009

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Pancreatic Cancer: An Imminent Threat

Matrisian,

Cancer Res

2014

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Pancreatic Cancer: Poor survival due to metastatic disease

5 year survival from diagnosis: <5

% (all-comers)

80% will present with invasive and metastatic disease at

diagnosis

Even with chemotherapy, median survival is ~6mo

20% will present with limited primary tumors with no metastatic disease

Most of these patients will undergo surgical

resection

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Surgical Treatment

Only chance at cure

Only indicated for patients with:

Limited tumor burden

No evidence of

mets

Satisfactory surgical risk

Whipple procedure v. distal

Relatively high morbidity

Post-op infection, leaks, bleeding

Brittle diabetes

Malnutrition and weight loss

Adjuvant

chemtherapy

recommended

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Poor survival even after surgery

Even

without clinical evidence of metastasis, 5y survival after resection is

poor (~20%)

Even with small tumors

Mostly due to metastatic

disease

Agarwal et al., Pancreas 2008

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Early warning signs of PDAC

Abrupt onset of diabetes in non-obese individuals over the age of 60

OR sudden insulin requirements or erratic blood sugar control

Depression

Evidence of pancreatic exocrine insufficiency

Foul smelling, floating stools

Malabsorption

Weight loss despite sufficient caloric intake

Non-specific symptoms:

Malaise, weight loss, anorexia, dull abdominal discomfort

Diagnostic test: pancreas protocol CT scan + IV contrast (though MR may be better)

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High risk groups

Chronic pancreatitis

Especially hereditary pancreatitis

Familial pancreatic cancer

≥2 first degree relatives with PDAC

Other genetic syndromes

Familial Atypical Multiple Mole Melanoma Syndrome (FAMMM; 38-fold increased risk)

Peutz-Jeghers

Syndrome (36% lifetime risk)

BRCA 2 mutation

Cystic fibrosis?

Screening: alternating annual EUS + MRI/CT

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Conclusions

Pancreatic cancer is a horrible disease

Median survival of 6-8mo

Will soon be the second leading cause of cancer-related deaths in the US

While not perfect, there are “early” warning signs

Abrupt onset diabetes, weight loss, depression

Surgery is the only treatment that may lead to durable cure at this point in time (~20% live to 5y)