Pancreatic Cancer: Pancreatic Cancer: The Silent KillerThe Silent Killer

By Suzanne SicaBy Suzanne Sica

Class 2008Class 2008

Case DemographicsCase Demographics

55 y/o Caucasian male presents to ER55 y/o Caucasian male presents to ER Chief c/o: Chief c/o:

RUQ and epigastric pain x 5 weeks worsened RUQ and epigastric pain x 5 weeks worsened with eating.with eating.

Significantly worsened sxs over last 2-3 weeksSignificantly worsened sxs over last 2-3 weeks Nausea, anorexia, and unexplained weight loss Nausea, anorexia, and unexplained weight loss

of 25 lbs.of 25 lbs. Proceeded to ER when:Proceeded to ER when:

Jaundice, light colored stools, and darker urine Jaundice, light colored stools, and darker urine x 2 days.x 2 days.

Denied fever, chills, or hematoemesis.Denied fever, chills, or hematoemesis.

Physical Physical ExaminationExamination

AbdomenAbdomen BS x 4 quadrantsBS x 4 quadrants Nontender and nondistended.Nontender and nondistended. Negative masses, hepatosplenomegaly, or Negative masses, hepatosplenomegaly, or

lymphadenopathy. lymphadenopathy. Negative Murphy’s Sign with inspiration.Negative Murphy’s Sign with inspiration.

Differential DiagnosisDifferential Diagnosis

What typically causes RUQ What typically causes RUQ pain associated with eating pain associated with eating with an otherwise normal with an otherwise normal exam?exam?

What does jaundice, light What does jaundice, light colored stools, and tea-colored stools, and tea-colored urine indicate? colored urine indicate? What could cause these What could cause these sxs?sxs?

What diagnosis would we What diagnosis would we be more concerned about be more concerned about if a fever was present?if a fever was present?

Abdominal UltrasoundAbdominal Ultrasound

Gall bladder distention with multiple calculi.Gall bladder distention with multiple calculi. Common bile duct ~6mm in diameter (higher limits of Common bile duct ~6mm in diameter (higher limits of

normal)normal) Negative wall thickening or pericholecystic fluid.Negative wall thickening or pericholecystic fluid. No free air nor intrahepatiic bile duct dilation.No free air nor intrahepatiic bile duct dilation.

Lab ResultsLab Results

Alkaline phosphatase of Alkaline phosphatase of 273, 273,

AST of 143, AST of 143, ALT of 288, ALT of 288, Total Bilirubin of 3.5, Total Bilirubin of 3.5, Direct Bilirubin of 2.0, Direct Bilirubin of 2.0, Amylase of 324. Amylase of 324.

Diagnosis/ TreatmentDiagnosis/ Treatment

Biliary Colic/ Biliary Colic/ CholedocholithiasisCholedocholithiasis

Cholecystectomy Cholecystectomy scheduled for next scheduled for next weekweek

Immediate ERCPImmediate ERCP Rule out ascending Rule out ascending

cholangitischolangitis Concerned about Concerned about

jaundice, PMH of jaundice, PMH of diabetes, and risk of diabetes, and risk of sepsis prior to surgerysepsis prior to surgery

Surgery Pimp QuestionsSurgery Pimp Questions

What are the symptoms of What are the symptoms of ascending cholangitis?ascending cholangitis?

ClueClue: One is a triad and the other is a : One is a triad and the other is a pentad.pentad.

Charcot’s TriadCharcot’s Triad

FeverFever Jaundice Jaundice RUQ PainRUQ Pain

Reynold’s PentadReynold’s Pentad

FeverFever JaundiceJaundiceRUQ PainRUQ PainConfusion (Altered Mental Status Confusion (Altered Mental Status

Changes)Changes)Hypotension (Shock)Hypotension (Shock)

ERCPERCP

Intervention used to treat conditions of the bile Intervention used to treat conditions of the bile and pancreatic duct, and make diagnoses.and pancreatic duct, and make diagnoses.

ERCP Findings/ ResultsERCP Findings/ Results

Performed by GastroenterologistPerformed by Gastroenterologist Common bile duct stenosis foundCommon bile duct stenosis found 10Fr 7cm biliary stent placed with 10Fr 7cm biliary stent placed with

difficulty 6cm into biliary ductdifficulty 6cm into biliary duct Suspicious for malignant pancreatic tumorSuspicious for malignant pancreatic tumor Hospital admissionHospital admission Following stent placement:Following stent placement:

Jaundice, light colored stools, and dark urine Jaundice, light colored stools, and dark urine resolved.resolved.

Repeat Abdominal CT Scan Repeat Abdominal CT Scan

Revealed 4.6cm x Revealed 4.6cm x 2.8cm pancreatic 2.8cm pancreatic head masshead mass

No pancreatic ductal No pancreatic ductal dilatationdilatation

Visualizes Visualizes metastases >1cm in metastases >1cm in size.size.

Explorative LaparoscopyExplorative Laparoscopy

Revealed 1mm Revealed 1mm white nodule on white nodule on lower lobe of liverlower lobe of liver

Nodule biopsied Nodule biopsied and sent for frozen and sent for frozen samplesample

Nodule was benignNodule was benign Proceed with Proceed with

Whipple’s Whipple’s ProcedureProcedure

Whipple’s Procedure: A Cure?Whipple’s Procedure: A Cure?

Contraindications to Whipple’s Contraindications to Whipple’s ProcedureProcedure

If superior mesenteric artery or portal vein If superior mesenteric artery or portal vein become involved.become involved.

Presence of ascites, nodal, or peritoneal Presence of ascites, nodal, or peritoneal metastases occur.metastases occur.

If tumor is >4cm- debatable.If tumor is >4cm- debatable.

ProblemProblem: Over 75% of patients present with : Over 75% of patients present with metastases initially.metastases initially.

NoteNote: CA 19-9 levels were documented at : CA 19-9 levels were documented at 1515.1515.

Whipple’s ProcedureWhipple’s Procedure

At the beginning of procedure,At the beginning of procedure,A 5mm white nodule was found on A 5mm white nodule was found on

Glissen’s capsule.Glissen’s capsule.Nodule was biopsied and sent for frozen Nodule was biopsied and sent for frozen

section.section.Metastatic cancer was confirmed.Metastatic cancer was confirmed.Whipple’s Procedure was aborted.Whipple’s Procedure was aborted.A palliative biliary bypass was performed. A palliative biliary bypass was performed.

(Roux-en-Y cholecystojejunostomy)(Roux-en-Y cholecystojejunostomy)

Prognosis for Metastatic Prognosis for Metastatic Pancreatic CancerPancreatic Cancer

Palliative TreatmentsPalliative Treatments Biliary bypass and common bile duct stentingBiliary bypass and common bile duct stenting

Alleviates future gastroduodenal obstruction. Alleviates future gastroduodenal obstruction. Avoids recurrent jaundice.Avoids recurrent jaundice.

Chemotherapy not recommended for Chemotherapy not recommended for pancreatic adenocarcinomaspancreatic adenocarcinomas

Doesn’t respond well.Doesn’t respond well.No benefit over supportive care.No benefit over supportive care.

Survival RatesSurvival Rates 3-6 months.3-6 months. Even had resection been performed, 5 year Even had resection been performed, 5 year

survival rate was ~20%.survival rate was ~20%.

ReferencesReferences Carson-DeWitt, Rosalyn, MD. (2007, June). Surgical Carson-DeWitt, Rosalyn, MD. (2007, June). Surgical

Procedures for Pancreatic Cancer. Retrieved September 1, Procedures for Pancreatic Cancer. Retrieved September 1, 1007 from EBSCO Publishing. 1007 from EBSCO Publishing.

Castillo, C.F., MD. Jimenez, R.E., MD. (2006, June 20). Castillo, C.F., MD. Jimenez, R.E., MD. (2006, June 20). Pancreatic Cancer: Palliation of Symptoms. Retrieved Pancreatic Cancer: Palliation of Symptoms. Retrieved August 31, 2007 from UptoDate database.August 31, 2007 from UptoDate database.

Erickson, R.A., MD. (2005, December 15). Pancreatic Erickson, R.A., MD. (2005, December 15). Pancreatic Cancer. Retrieved July 20, 2007 from Emedicine database.Cancer. Retrieved July 20, 2007 from Emedicine database.

Merchant, N.B., MD. Conlon, K.C., MD. (1998). Merchant, N.B., MD. Conlon, K.C., MD. (1998). “Laparoscopic Evaluation in Pancreatic Cancer.” Semin. “Laparoscopic Evaluation in Pancreatic Cancer.” Semin. Surgical Oncology. 15:155-165.Surgical Oncology. 15:155-165.

Parker, Stephen BSc. (2007, June 3). Pancreatic Carcinoma. Parker, Stephen BSc. (2007, June 3). Pancreatic Carcinoma. Retrieved August 31, 2007 from Retrieved August 31, 2007 from http://www.surgicaltutor.org.uk/defaulthome.htm?system/ahttp://www.surgicaltutor.org.uk/defaulthome.htm?system/abdomen/pancreatic_ca.htm~rightbdomen/pancreatic_ca.htm~right