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Pancreatic Cancer: Case and Discussion PowerPoint Presentation

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Description : This medical presentation on cancer titled "Pancreatic Cancer: Case and Discussion" presents a clinical case on pancreatic cancer and discusses its threats, risk factors and treatment.

Tags : Cancer, Pancreatic cancer, Chronic pancreatitis, Screening, alternating annual EUS + MRI/CT

Published on : May 03, 2021 | Views : 2646 | Downloads : 4

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Slide 1-

Pancreatic Cancer: Case and Discussion Andrew D. Rhim, MD University of Michigan Medical School
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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 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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ppt slide no 11 content not found
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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)