Pancreatic Cancer:
Case and Discussion
Andrew D. Rhim, MD
University 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
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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
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Constitutional: He is oriented to person, place, and time. He appears well-developed and wellnourished. 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
98
10
4.3
30
0.98
31.5
241
ALT = 37
AST = 36
TBili = 1.6
Alk Phos = 99
Alb = 4.1
1.0
4.4
14.8
365
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.
B.
C.
D.
E.
Repeat cross sectional imaging (MRCP)
Endoscopic ultrasound +/- FNA
EGD + colonoscopy
Treat patient for IBS
Pancreatic enzyme supplementation
Next steps?
A.
B.
C.
D.
E.
Repeat cross sectional imaging (MRCP)
Endoscopic ultrasound +/- FNA
EGD + colonoscopy
Treat patient for IBS
Pancreatic enzyme supplementation
Why? High suspicion for neoplasm
• HPI:
– Vague, dull discomfort/pressure starting 1020 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 19952005
• 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; 38fold 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)