Transcript Pancreatic Cancer and Surgical Intervention

Pancreatic Cancer:
The Silent Killer
By Suzanne Sica
Class 2008
Case Demographics
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55 y/o Caucasian male presents to ER
Chief c/o:
 RUQ and epigastric pain x 5 weeks worsened with
eating.
Significantly worsened sxs over last 2-3 weeks
 Nausea, anorexia, and unexplained weight loss of 25
lbs.
Proceeded to ER when:
 Jaundice, light colored stools, and darker urine x 2
days.
 Denied fever, chills, or hematoemesis.
Physical Examination
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Abdomen
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BS x 4 quadrants
Nontender and nondistended.
Negative masses, hepatosplenomegaly, or
lymphadenopathy.
Negative Murphy’s Sign with inspiration.
Differential Diagnosis
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What typically causes RUQ
pain associated with eating
with an otherwise normal
exam?
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What does jaundice, light
colored stools, and tea-colored
urine indicate? What could
cause these sxs?
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What diagnosis would we be
more concerned about if a
fever was present?
Abdominal Ultrasound
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Gall bladder distention with multiple calculi.
Common bile duct ~6mm in diameter (higher limits of normal)
Negative wall thickening or pericholecystic fluid.
No free air nor intrahepatiic bile duct dilation.
Lab Results
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Alkaline phosphatase of 273,
AST of 143,
ALT of 288,
Total Bilirubin of 3.5,
Direct Bilirubin of 2.0,
Amylase of 324.
Diagnosis/ Treatment
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Biliary Colic/
Choledocholithiasis
Cholecystectomy
scheduled for next week
Immediate ERCP
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Rule out ascending
cholangitis
Concerned about jaundice,
PMH of diabetes, and risk
of sepsis prior to surgery
Surgery Pimp Questions
What are the symptoms of
ascending cholangitis?
Clue: One is a triad and the other is a pentad.
Charcot’s Triad
Fever
 Jaundice
 RUQ Pain
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Reynold’s Pentad
Fever
 Jaundice
 RUQ Pain
 Confusion (Altered Mental Status
Changes)
 Hypotension (Shock)
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ERCP
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Intervention used to treat conditions of the bile
and pancreatic duct, and make diagnoses.
ERCP Findings/ Results
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Performed by Gastroenterologist
Common bile duct stenosis found
10Fr 7cm biliary stent placed with difficulty 6cm
into biliary duct
Suspicious for malignant pancreatic tumor
Hospital admission
Following stent placement:
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Jaundice, light colored stools, and dark urine
resolved.
Repeat Abdominal CT Scan
Revealed 4.6cm x
2.8cm pancreatic
head mass
 No pancreatic ductal
dilatation
 Visualizes metastases
>1cm in size.
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Explorative Laparoscopy
Revealed 1mm white
nodule on lower lobe
of liver
 Nodule biopsied and
sent for frozen
sample
 Nodule was benign
 Proceed with
Whipple’s Procedure
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Whipple’s Procedure: A Cure?
Contraindications to Whipple’s
Procedure
If superior mesenteric artery or portal vein
become involved.
 Presence of ascites, nodal, or peritoneal
metastases occur.
 If tumor is >4cm- debatable.
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Problem: Over 75% of patients present with
metastases initially.
 Note: CA 19-9 levels were documented at 1515.
Whipple’s Procedure
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At the beginning of procedure,
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5mm white nodule was found on Glissen’s
capsule.
 Nodule was biopsied and sent for frozen
section.
 Metastatic cancer was confirmed.
 Whipple’s Procedure was aborted.
 A palliative biliary bypass was performed.
(Roux-en-Y cholecystojejunostomy)
Prognosis for Metastatic
Pancreatic Cancer
Palliative Treatments
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Biliary bypass and common bile duct stenting
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Alleviates future gastroduodenal obstruction.
Avoids recurrent jaundice.
Chemotherapy not recommended for pancreatic
adenocarcinomas
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Doesn’t respond well.
No benefit over supportive care.
Survival Rates
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3-6 months.
Even had resection been performed, 5 year survival
rate was ~20%.
References
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Carson-DeWitt, Rosalyn, MD. (2007, June). Surgical Procedures for
Pancreatic Cancer. Retrieved September 1, 1007 from EBSCO
Publishing.
Castillo, C.F., MD. Jimenez, R.E., MD. (2006, June 20). Pancreatic
Cancer: Palliation of Symptoms. Retrieved August 31, 2007 from
UptoDate database.
Erickson, R.A., MD. (2005, December 15). Pancreatic Cancer.
Retrieved July 20, 2007 from Emedicine database.
Merchant, N.B., MD. Conlon, K.C., MD. (1998). “Laparoscopic
Evaluation in Pancreatic Cancer.” Semin. Surgical Oncology. 15:155165.
Parker, Stephen BSc. (2007, June 3). Pancreatic Carcinoma.
Retrieved August 31, 2007 from
http://www.surgicaltutor.org.uk/defaulthome.htm?system/abdomen/
pancreatic_ca.htm~right