Pancreatic Cancer: Case and Discussion Andrew D. Rhim, MD University of Michigan Medical School.

Pancreatic Cancer: Case and Discussion

Andrew D. Rhim, MDUniversity of Michigan

Medical School

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

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)

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)

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

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

Family history• Colon cancer in father (60)• Unknown cancer in mother, sister, maternal

aunt, maternal uncle.

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.

Labs

144

4.3

98

30

10

0.98241

1.0

31.54.4

14.8365

ALT = 37AST = 36TBili = 1.6Alk Phos = 99Alb = 4.1

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

Next steps?A. Repeat cross sectional imaging (MRCP)B. Endoscopic ultrasound +/- FNAC. EGD + colonoscopyD. Treat patient for IBSE. Pancreatic enzyme supplementation

Next steps?A. Repeat cross sectional imaging (MRCP)B. Endoscopic ultrasound +/- FNAC. EGD + colonoscopyD. Treat patient for IBSE. Pancreatic enzyme supplementation

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

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

Mass in body of pancreas

Diagnosis:Pancreatic ductal adenocarcinoma,Stage 1

Treatment:Surgical resection +Adjuvant chemo

Pancreatic Cancer Epidemiology• Incidence: 11.7 per 100,000

– Rising incidence• 6.7% increase 19952005

• 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

Pancreatic Cancer: An Imminent Threat

Matrisian,Cancer Res 2014

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

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

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

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)

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

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)