Question of the Week # 216

216 )  A 75 year old woman with past medical history of hypertension and diabetes is evaluated in your office for 20 lb weight loss. She reports decreased appetite and depressed mood for the past 6 months. Her history is significant for chronic smoking 1 pack per day for last 50 years. She lives alone and does all her daily activities by herself.  She has no known cardiac problems. She denies shortness of breath or cough. On examination, scleral icterus is noted. Lab studies show total bilirubin elevated at 10gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass. There are no distant metastases. A chest X-Ray is normal. CA 19-9 level 1400U/ml.  Which of the following is the most appropriate next  step ?

A) Hospice Evaluation

B) Surgical resection

C) Fine needle aspiration biopsy

D) Chemotherapy

E) Radiation therapy

10 Responses

  1. C…. always we need confirmatory study in oncology before any treatment

  2. ccc

  3. Borderline resectable tumor, because of invasion into the SMV/SMA,,,, treatment for such thing would be either surgery or a trial of chemotherapy/or chemoradiotherapy then re staging & Surgery thereafter……
    I would go for E.

  4. answer : fine needle biopsy

    resectability criteria : absence of vascular invasion : SMA , PV , Celiac axis , Hepatic .a

    vinette : triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass.

    FNA is needed as prerequisite for Chemo and radiation

    Just my 2 cents . Correct me if I’m wrong . Thanks .

  5. E= non resectable

  6. why not chemo?

    answer is chemo/rad

  7. The majority of patients with stage IIB and III have tumours that encase blood vessels. Patients who present borderline resectable disease may benefit from preoperative therapy (chemoradiation or induction chemotherapy followed by chemoradiation) in order to increase the rate of R0 resections.

    so answer is chemo

  8. C)

    Ca19-9 > 100 is highly specific for pancreatic cancer.
    It is not necessary to obtain a biopsy.

    Historically, vascular involvement has been considered a contraindication to resective cure. However, the invasion of the superior mesenteric or portal vein is no longer an absolute contraindication. These veins can be resected partially with as much as 50% narrowing of the lumen. In addition, complete reconstruction is possible, especially using native veins as replacement (ie, internal jugular, greater saphenous, or splenic).

    The NCCN’s 2011 guidelines recommend that decisions about treatment and resectability involve input from a multidisciplinary group of specialists. The panel also agreed that selecting patients for surgery should be based on the probability of cure as determined by resection margins. Other factors include comorbidities, overall performance, and age.

    So it’s surgery then chemotherapy for metastatic disease with or without radiation.

    The patient is 75 with co-morbidities but the tumour is relatively localized. With her DM/HTN history though, I wonder if she has sufficient patent native veins to use as replacement as suggested in the Medscape article.
    I think the issue here is that she is old and has co-morbidities. Her tumor marker is also through the roof! Taking into account the poor prognosis that pancreatic ca portends, I am inclined to think she might need hospice evaluation. 😦 Why put her through all the suffering? (Of course, the options can be presented to her and the family.)

    Option A.

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