Pancreatic Adenocarcinoma with Case

00:01 Let's move to our next case.

00:04 A 59-year-old man is seen in clinic for indigestion, nausea and the yellowing of his eyes for the past six months.

00:11 He has three to four voluminous stools per day.

00:15 His stools are clay colored and urine is dark.

00:19 He lost 9 kg unintentionally in the last six months.

00:23 His medical history is significant for a 50 pack-year smoking history and prediabetes.

00:29 Vitals are normal. BMI is 21.

00:32 Exam is notable for temporal wasting, scleral icterus and epigastric tenderness without rebound or guarding.

00:39 His labs reveal a total bilirubin of 2.8 and an elevated CA 19-9.

00:45 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.

00:59 So at this point, we should be thinking about different types of cancer.

01:03 In addition, he has cachexia and jaundice on exam.

01:08 And his elevated total bilirubin shows that he has cholestasis.

01:14 This elevated CA 19-9 is neither a sensitive nor specific finding, but we'll discuss that later.

01:23 That brings us to pancreatic adenocarcinoma.

01:27 Pancreatic adenocarcinoma can present with jaundice.

01:30 From the jaundice, patients may describe dark urine and light-colored stools.

01:34 They may have nausea, pain after eating, unintended weight loss.

01:39 And they may have upper abdominal pain as well as back pain.

01:44 On physical exam, they often appear cachectic. They may have muscle wasting.

01:50 They're often jaundiced and there are several particular eponyms that you should know in relation to pancreatic cancer.

01:57 One of them is Virchow's node.

01:59 This is when a patient has a palpable, supraclavicular lymphadenopathy.

02:05 The second eponym you should know is Courvoisier's sign.

02:09 This is a when you can actually palpate a gallbladder.

02:13 And this is from distal bile duct compression leading to a palpable a gallbladder.

02:18 The last eponym is Trousseau's syndrome.

02:21 This is when patients with pancreatic cancer can develop migratory thrombophlebitis.

02:26 Unfortunately with pancreatic cancers, the prognosis is very poor.

02:32 A five-year survival rate is only about 5%.

02:35 And this is because patients often present with very vague symptoms and at the time of diagnosis, often have very late stage disease.

02:43 So, what are the risk factors for pancreatic cancer? Advanced age, so greater than 50 years.

02:50 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.

03:05 So the diagnosis is primarily done with imaging.

03:08 A CT of the abdomen has a very good sensitivity, around 90% for detecting pancreatic cancer.

03:15 Shown here is a CT of the abdomen during the pancreatic phase of contrast showing an isodense adenocarcinoma in the head of the pancreas.

03:25 You may also do an endoscopic ultrasound for small tumors that you cannot detect on CT scan.

03:31 And with this procedure, you can also do what's called an FNA or a Fine Needle Aspiration to obtain results for a biopsy.

03:39 When the diagnosis is equivocal, you may also do MRCP or ERCP to help you confirm the diagnosis.

03:47 Some lab studies may be helpful in the diagnosis of this disease.

03:53 You want to check a liver panel to evaluate for cholestasis.

03:57 A serum lipase may be helpful to make sure that the patient does not also have pancreatitis from obstruction of the pancreatic duct.

04:05 And as we mentioned, there is the CA 19-9 tumor marker.

04:09 Keep in mind this has poor sensitivity and specificity for this diagnosis.

04:14 But checking it may be useful for prognosis and for monitoring patients' response to treatment.

04:21 So, the staging of pancreatic adenocarcinoma depends on tumor, nodal and metastasis staging.

04:29 In general, stage I disease is resectable.

04:34 This is when it's confined within the pancreas.

04:37 Stage II disease may be borderline resectable.

04:41 In these cases, they may have local spread just outside the pancreas to adjacent lymph nodes.

04:47 Once you reach stage III, this is when you have had spread to multiple lymph nodes or major blood vessels near the pancreas.

04:55 This has now become unresectable disease. And lastly stage IV, is metastatic cancer.

05:02 When you have now spread of the cancer to distant organs, this is not resectable.

05:06 So, as far as treatment goes, surgical resection is the only curative therapy.

05:12 But as we spoke about earlier, very limited stages of pancreatic cancer can be treated with this type of surgery.

05:19 Here on the right is one of the procedures that is done for pancreatic cancer called a Whipple procedure or a pancreaticoduodenectomy.

05:28 This is when you remove the head of the pancreas.

05:31 And then the remaining pancreas, bile duct, and stomach are then attached to the small intestine.

05:37 For unresectable disease, the main stay of treatment involves chemotherapy plus or minus radiation.

05:46 This tends to be with gemcitabine-based regimens.

05:49 We do have newer regimens using five fluorouracil.

05:52 And there are always evolving therapies with immunotherapy for this cancer.

05:58 So now let's return to our case.

06:02 A 59-year-old man, now with obstructive jaundice, weight loss and indigestion.

06:07 We know he's a smoker and has prediabetes both of which are risk factors for these type of cancer.

06:12 He is cachectic. He has cholestasis on his labs.

06:16 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.

06:27 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.

06:39 Thank you very much for your attention.