PANCE Blueprint GI and Nutrition (10%)

Pancreatic neoplasms (ReelDx + Lecture)

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VIDEO-CASE-PRESENTATION-REEL-DX

Pancreatic Cancer Patient will present as → a 68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable non-tender gallbladder and clay-colored stool. Labs show a total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150.

What tumor marker can be used to follow pancreatic cancer?
CA-19-9

Describe Courvoisier's sign.
Nontender, palpable gallbladder which may indicate pancreatic neoplasm.

Most common is ductal adenocarcinoma usually at the head of the pancreas

  • Abdominal pain, jaundice, enlarged palpable gallbladder in 40% of patients (Courvoisier's sign), light-colored stools, dark urine, pruritus, weight loss
  • Associated with cigarette smoking, pancreatitis, diabetes mellitus and obesity

Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle).

  • It takes its supply from lymph vessels in the abdominal cavity. Virchow's node is also sometimes coined “the seat of the devil” given its ominous association with malignant disease
"Pain of pancreatic cancer is often lessened by sitting and leaning forward (just like pancreatitis). This indicated that the lesion has spread beyond the pancreas and is inoperable."

Risk factors: smoking, alcohol, obesity and chronic pancreatitis.

Diagnose with abdominal CT scan - 75% show tumor at the head of the pancreas, 20% in body and 10% in the tail

  • Increased amylase (if tumor obstructs ducts)
  • Increased direct bilirubin
  • Increased CEA
  • Glucose intolerance
  • ERCP - stenosis or obstruction of pancreatic ducts
  • Tumor Marker: CA 19-9 - not diagnostic but can be used to follow response to therapy

Treatment is whipple procedure: remove antrum of stomach, part of duodenum, head of pancreas, gall bladder.

  • Poor prognosis 2-5% five year survival

Question 1
A 69-year old man presents with epigastric pain which radiates to his back, progressive weight loss, jaundice, and pruritus. On physical examination, patient looks cachectic, is icteric, has scratch marks, palpable gallbladder. His fasting blood sugar (FBS) is 13mg/dl. What is the most likely diagnosis?
A
Pancreatic cancer
B
Gastric cancer
Hint:
Gastric cancer cannot cause pruritus and enlargement of the gallbladder.
C
Gastric ulcer
Hint:
Gastric ulcer doesn’t present as jaundice and pruritus.
D
Hepatocellular carcinoma
Hint:
Hepatocellular carcinoma does not cause enlargement of the gallbladder.
Question 1 Explanation: 
Epigastric pain which radiates to the back with weight loss, jaundice, pruritus, palpable gall bladder and a deranged FBS strongly suggests pancreatic cancer.
Question 2
If you could order only one investigation at this time, which one of the following would you order?
A
magnetic resonance imaging scan of the abdomen
B
gastroscopy
C
dual-phase helical computed tomography (CT) scan of the abdomen
D
colonoscopy
Question 2 Explanation: 
the investigation of choice is a dual-phase helical CT scan of the abdomen. No other test provides such high sensitivity and specificity. The sensitivity of the CT scan in the diagnosis of adenocarcinoma of the pancreas is between 95% and 98%; that is, only 1 of every 20 patients with adenocarcinoma will have false-negative CT scan results.
Question 3
What is the most clearly established risk factor for the disease described?
A
alcohol consumption
B
cigarette smoking
C
high fat intake
D
environmental toxins
E
previous exposure to radiation
Question 3 Explanation: 
The most likely established risk factor for adenocarcinoma of the pancreas is cigarette smoking. There is some controversy regarding alcohol intake, but most authorities consider it a significant risk factor as well.
Question 4
Which of the following treatment modalities provide cure for pancreatic cancer when indicated?
A
Pancreaticoduodenectomy (Whipple procedure)
B
Chemotherapy
C
Radiotherapy
D
None of the above
Question 4 Explanation: 
Carcinoma of the head of the pancreas is resectable in only 20% of patients (Whipple procedure). The prognosis for adenocarcinoma of the pancreas is dismal. The overall 5-year survival rate is approximately 4%; localized resectable disease has a 20% survival rate. However, moderately encouraging results have been obtained with the use of gemcitabine and other adjuvant, radiograph, and molecular biologic therapies
Question 5
Which of the following statements is not true concerning pancreatic carcinoma?
A
Pancreatic carcinoma is the 5th leading cause of cancer death in US.
B
Men are affected twice as often as women.
C
75% occur in the tail.
D
May be associated with depression.
Question 5 Explanation: 
75% of pancreatic carcinoma occur in the head of pancreas. 5-10% occur in the tail. All other statements are true.
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