Let's move to our next case.
A 59-year-old man is seen in clinic for indigestion,
nausea and the yellowing of his eyes for the past six months.
He has three to four voluminous stools per day.
His stools are clay colored and urine is dark.
He lost 9 kg unintentionally in the last six months.
His medical history is significant for a 50 pack-year smoking history and prediabetes.
Vitals are normal. BMI is 21.
Exam is notable for temporal wasting, scleral icterus and epigastric tenderness
without rebound or guarding.
His labs reveal a total bilirubin of 2.8 and an elevated CA 19-9.
So we're asked, what is the best initial imaging test for diagnosis?
So we can point out here that he has obstructive jaundice with weight loss and indigestion,
and a smoker with prediabetes.
So at this point, we should be thinking about different types of cancer.
In addition, he has cachexia and jaundice on exam.
And his elevated total bilirubin shows that he has cholestasis.
This elevated CA 19-9 is neither a sensitive nor specific finding, but we'll discuss that later.
That brings us to pancreatic adenocarcinoma.
Pancreatic adenocarcinoma can present with jaundice.
From the jaundice, patients may describe dark urine and light-colored stools.
They may have nausea, pain after eating, unintended weight loss.
And they may have upper abdominal pain as well as back pain.
On physical exam, they often appear cachectic. They may have muscle wasting.
They're often jaundiced and there are several particular eponyms
that you should know in relation to pancreatic cancer.
One of them is Virchow's node.
This is when a patient has a palpable, supraclavicular lymphadenopathy.
The second eponym you should know is Courvoisier's sign.
This is a when you can actually palpate a gallbladder.
And this is from distal bile duct compression leading to a palpable a gallbladder.
The last eponym is Trousseau's syndrome.
This is when patients with pancreatic cancer can develop migratory thrombophlebitis.
Unfortunately with pancreatic cancers, the prognosis is very poor.
A five-year survival rate is only about 5%.
And this is because patients often present with very vague symptoms
and at the time of diagnosis, often have very late stage disease.
So, what are the risk factors for pancreatic cancer?
Advanced age, so greater than 50 years.
A family history of pancreatic cancer, cigarette smoking, obesity and diabetes
and rarely, introductal papillary mucinous neoplasms
which are premalignant lesions that can occur in the pancreas.
So the diagnosis is primarily done with imaging.
A CT of the abdomen has a very good sensitivity, around 90% for detecting pancreatic cancer.
Shown here is a CT of the abdomen during the pancreatic phase of contrast
showing an isodense adenocarcinoma in the head of the pancreas.
You may also do an endoscopic ultrasound for small tumors that you cannot detect on CT scan.
And with this procedure, you can also do what's called an FNA
or a Fine Needle Aspiration to obtain results for a biopsy.
When the diagnosis is equivocal, you may also do MRCP or ERCP to help you confirm the diagnosis.
Some lab studies may be helpful in the diagnosis of this disease.
You want to check a liver panel to evaluate for cholestasis.
A serum lipase may be helpful to make sure that the patient
does not also have pancreatitis from obstruction of the pancreatic duct.
And as we mentioned, there is the CA 19-9 tumor marker.
Keep in mind this has poor sensitivity and specificity for this diagnosis.
But checking it may be useful for prognosis and for monitoring patients' response to treatment.
So, the staging of pancreatic adenocarcinoma depends on tumor, nodal and metastasis staging.
In general, stage I disease is resectable.
This is when it's confined within the pancreas.
Stage II disease may be borderline resectable.
In these cases, they may have local spread just outside the pancreas to adjacent lymph nodes.
Once you reach stage III, this is when you have had spread to multiple lymph nodes
or major blood vessels near the pancreas.
This has now become unresectable disease. And lastly stage IV, is metastatic cancer.
When you have now spread of the cancer to distant organs, this is not resectable.
So, as far as treatment goes, surgical resection is the only curative therapy.
But as we spoke about earlier, very limited stages of pancreatic cancer
can be treated with this type of surgery.
Here on the right is one of the procedures
that is done for pancreatic cancer called a Whipple procedure or a pancreaticoduodenectomy.
This is when you remove the head of the pancreas.
And then the remaining pancreas, bile duct, and stomach are then attached to the small intestine.
For unresectable disease, the main stay of treatment
involves chemotherapy plus or minus radiation.
This tends to be with gemcitabine-based regimens.
We do have newer regimens using five fluorouracil.
And there are always evolving therapies with immunotherapy for this cancer.
So now let's return to our case.
A 59-year-old man, now with obstructive jaundice, weight loss and indigestion.
We know he's a smoker and has prediabetes
both of which are risk factors for these type of cancer.
He is cachectic. He has cholestasis on his labs.
And although we said that CA 19-9 is not sensitive nor specific,
all of the clinical features combined with his findings support a diagnosis of pancreatic cancer.
So the best initial imaging test for diagnosis would be a CT of the abdomen
which has 90% sensitivity and can help us with staging information for this disease.
Thank you very much for your attention.