Transcript SYB Case 2 - MyPACS.net

SYB Case 3
By: Amy
History
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55 y/o male
Presented with epigastric pain in Nov 2007
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CT/MRI of abdomen and additional workup was
negative
Endoscopy revealed a gastric ulcer  treated
Then presented twice in August 2008 with
recurrent abdominal pain, was given vicoden,
and was told to f/u with his primary care doc
PMHx includes Afib and PE for which he
takes coumadin; pt is a smoker
CT of Abdomen performed on 9/5/08
Liver mets and a mass in body of pancreas
Additional history
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Underwent liver biopsy on 9/5/08, which
showed for malignant cells consistent with
adenocarcinoma  diagnosed with
metastatic adenocarcinoma of the pancreas
Started on systemic chemotherapy of
gemcitabine with Tarceva on 9/12/08
Because of the liver biopsy, his Coumadin
was stopped and he subsequently developed
bilateral leg DVTs  placed back on
coumadin
Repeat CT to determine response to therapy
on 1/23/09
Is the patient’s disease responding well to
chemo?
No; there has been significant interval progression
of the liver mets and main pancreatic tumor.
Liver mets increasing in size and number, pancreatic mass, and probable splenic infarct
Hepatic fluid collection
Lytic mets to spine at T11 with mild
compression of the vertebral body
Thrombus in the apex of the left ventricle
Renal cysts, IVC filter, and infrarenal AAA with thrombus
Pancreatic cancer
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Cancer of the exocrine pancreas is the 4th leading
cause of cancer-related death in the U.S.
The dx is typically made radiographically and
histologically
Surgical resection is the only potentially curative
treatment
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Because of the late-presentation in many patients, only 1520% of patients are candidates for pancreatectomy
Prognosis is often poor even in those pts with potentially
resectable disease
There is a particularly high incidence of
thromboembolic (both venous and arterial) events,
particularly in the setting of advanced disease
Imaging for Pancreatic Cancer
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Ultrasound – usually performed in pts presenting with jaundice; dilated bile ducts or a
mass in the head of the pancreas are seen
CT and CT angiography – better sensitivity (85-90%) and similar specificity (90-95%) to
US, particularly useful in pts who are not jaundiced; usually see bile and pancreatic duct
dilation, a mass lesion in the pancreas, and/or extrapancreatic mets
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Contrast is better for staging
CT angiogram can provide information about major vessel involvement (i.e. portal vein, SMA, and
SMV) that may indicate surgical unresectability
ERCP – sensitivity and specificity are 90-95%; most useful if CT or US does not reveal a
mass lesion or if chronic pancreatitis is in the DDx; findings include strictures or
obstruction of the common bile and pancreatic ducts (“double duct” sign), and absence of
chronic pancreatitis changes
Endoscopic ultrasound – operator-dependent; most useful for a dx of small tumors (>23 cm diameter) and evaluation of nodal and major vascular involvement (except for the
SMA and SMV); also allows for biopsy and staging
MRI and MRCP – routine MRI has no significant diagnostic advantage over contrast
enhanced CT for staging; therefore, the choice of MRI or CT depends on the clinician’s
preference; helical CT angiography is usually preferred to MRI alone
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MRCP is better than CT for defining the anatomy of the biliary tree and pancreatic duct, has the
capability to evaluate the bile ducts both above and below a stricture, and can identify intrahepatic
mass lesions; is also does not require contrast
MRCP is preferred to ERCP in pts with bile duct obstruction due to chronic pancreatitis and in
pts in whom ERCP was unsuccessful
Thrombosis in cancer
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Cancer causes a hypercoagulable state
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Thrombotic episodes may precede the dx of malignancy by months
or years
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Cancer pts often have multiple comorbidities as well, including
hospitalizations, immobilization, surgery, advanced age, metastatic disease,
presence of a central venous catheter, and chemotherapy (including
gemcitabine as in this patient)
Particularly true for carcinomas of the GI tract, ovaries, prostate, and lung
Can present in many different ways, including Trousseau’s syndrome,
idiopathic DVT, nonbacterial thrombotic endocarditis, DIC, thrombotic
microangiopathy (i.e. hemolytic-uremic syndrome), or arterial thrombosis
Clinical thromboembolism is the second leading cause of death in
pts with overt malignant disease
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In one study, 30% of pts who died of pancreatic cancer had evidence of
thrombosis
50% of pts with pancreatic cancer in the body or tail had evidence of
thrombosis
Thrombosis in cancer
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Trousseau’s syndrome (migratory superficial thrombophlebitis)
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Rare variant of venous thrombosis characterized by a recurrent and
migratory pattern and involvement of superficial veins, frequently in
unusual sites such as the arm or chest
The pt usually has an occult tumor which is not always detectable at the
time of presentation
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The tumor us usually an adenocarcinoma when discovered
Most common tumors in pts with this syndrome are pancreas (24%), lung
(20%), prostate, stomach, acute leukemia, and colon
Treatment is difficult because Coumadin appears to have no effect, while
heparin can relieve some of the manifestations
Venous thromboembolism risk
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Increased in pts with malignancy, particularly with distant metastases
Highest risk in pts with hematologic malignancies, lung, GI tract, brain,
kidney, and breast cancers
Risk is highest in the first 3 months following a dx of malignancy and
decreases after that period of time
VTE at least one year after the dx of a malignancy may indicate a
second malignancy
What to do?
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There is an absence of prospective studies demonstrating
cost-effectiveness or improved survival with aggressive
diagnostic testing for malignancy in patients with
idiopathic DVT’s
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Therefore, at this time, only a careful history, physical exam
(including rectal and pelvic exams), and routine lab testing (i.e.
CBC, lytes, calcium creatinine, LFT’s, UA, chest radiograph,
and PSA in men over age 50) should be performed
Any abnormalities on these tests should then be more
thoroughly evaluated
However, pts who present with recurrent idiopathic
DVT’s represent a high-risk group and an aggressive
search for malignancy should be undertaken in these
patients
References
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UpToDate; all accessed 1/26/09
 Bauer, K. Drug-induced thrombosis and
vascular disease in patients with malignancy.
 Bauer, K. Hypercoagulable disorders
associated with malignancy.
 Steer, M. Clinical manifestations, diagnosis,
and surgical staging of exocrine pancreatic
cancer.