SYB Case 3SYB Case 3

By: AmyBy: Amy

HistoryHistory 55 y/o male55 y/o male Presented with epigastric pain in Nov 2007Presented with epigastric pain in Nov 2007

CT/MRI of abdomen and additional workup was CT/MRI of abdomen and additional workup was negativenegative

Endoscopy revealed a gastric ulcer Endoscopy revealed a gastric ulcer treated treated Then presented twice in August 2008 with Then presented twice in August 2008 with

recurrent abdominal pain, was given vicoden, and recurrent abdominal pain, was given vicoden, and was told to f/u with his primary care docwas told to f/u with his primary care doc

PMHx includes Afib and PE for which he takes PMHx includes Afib and PE for which he takes coumadin; pt is a smokercoumadin; pt is a smoker

CT of Abdomen performed on 9/5/08CT of Abdomen performed on 9/5/08

Liver mets and a mass in body of pancreas

Additional historyAdditional history Underwent liver biopsy on 9/5/08, which showed Underwent liver biopsy on 9/5/08, which showed

for malignant cells consistent with for malignant cells consistent with adenocarcinoma adenocarcinoma diagnosed with metastatic diagnosed with metastatic adenocarcinoma of the pancreasadenocarcinoma of the pancreas

Started on systemic chemotherapy of gemcitabine Started on systemic chemotherapy of gemcitabine with Tarceva on 9/12/08with Tarceva on 9/12/08

Because of the liver biopsy, his Coumadin was Because of the liver biopsy, his Coumadin was stopped and he subsequently developed bilateral stopped and he subsequently developed bilateral leg DVTs leg DVTs placed back on coumadin placed back on coumadin

Repeat CT to determine response to therapy on Repeat CT to determine response to therapy on 1/23/091/23/09

Is the patient’s disease responding well to chemo?

Liver mets increasing in size and number, pancreatic mass, and probable splenic infarct

No; there has been significant interval progression of the liver mets and main pancreatic tumor.

Lytic mets to spine at T11 with mild compression of the vertebral body

Hepatic fluid collection

Thrombus in the apex of the left ventricle

Renal cysts, IVC filter, and infrarenal AAA with thrombus

Pancreatic cancerPancreatic cancer Cancer of the exocrine pancreas is the 4th Cancer of the exocrine pancreas is the 4th

leading cause of cancer-related death in the leading cause of cancer-related death in the U.S.U.S.

The dx is typically made radiographically and The dx is typically made radiographically and histologicallyhistologically

Surgical resection is the only potentially Surgical resection is the only potentially curative treatmentcurative treatment Because of the late-presentation in many patients, Because of the late-presentation in many patients,

only 15-20% of patients are candidates for only 15-20% of patients are candidates for pancreatectomypancreatectomy

Prognosis is often poor even in those pts with Prognosis is often poor even in those pts with potentially resectable diseasepotentially resectable disease

There is a particularly high incidence of There is a particularly high incidence of thromboembolic (both venous and arterial) thromboembolic (both venous and arterial) events, particularly in the setting of advanced events, particularly in the setting of advanced diseasedisease

Imaging for Pancreatic Imaging for Pancreatic CancerCancer

UltrasoundUltrasound – usually performed in pts presenting with jaundice; dilated – usually performed in pts presenting with jaundice; dilated bile ducts or a mass in the head of the pancreas are seenbile ducts or a mass in the head of the pancreas are seen

CT and CT angiographyCT and CT angiography – better sensitivity (85-90%) and similar – better sensitivity (85-90%) and similar specificity (90-95%) to US, particularly useful in pts who are not jaundiced; 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, usually see bile and pancreatic duct dilation, a mass lesion in the pancreas, and/or extrapancreatic metsand/or extrapancreatic mets

Contrast is better for staging Contrast is better for staging CT angiogram can provide information about major vessel involvement (i.e. portal CT angiogram can provide information about major vessel involvement (i.e. portal

vein, SMA, and SMV) that may indicate surgical unresectability vein, SMA, and SMV) that may indicate surgical unresectability ERCPERCP – sensitivity and specificity are 90-95%; most useful if CT or US does – 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 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 include strictures or obstruction of the common bile and pancreatic ducts (“double duct” sign), and absence of chronic pancreatitis changes(“double duct” sign), and absence of chronic pancreatitis changes

Endoscopic ultrasoundEndoscopic ultrasound – operator-dependent; most useful for a dx of – operator-dependent; most useful for a dx of small tumors (>2-3 cm diameter) and evaluation of nodal and major small tumors (>2-3 cm diameter) and evaluation of nodal and major vascular involvement (except for the SMA and SMV); also allows for biopsy vascular involvement (except for the SMA and SMV); also allows for biopsy and stagingand staging

MRI and MRCPMRI and MRCP – routine MRI has no significant diagnostic advantage – routine MRI has no significant diagnostic advantage over contrast enhanced CT for staging; therefore, the choice of MRI or CT over contrast enhanced CT for staging; therefore, the choice of MRI or CT depends on the clinician’s preference; helical CT angiography is usually depends on the clinician’s preference; helical CT angiography is usually preferred to MRI alonepreferred to MRI alone

MRCP is better than CT for defining the anatomy of the biliary tree and 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 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 below a stricture, and can identify intrahepatic mass lesions; is also does not require contrastrequire contrast

MRCP is preferred to ERCP in pts with bile duct obstruction due to chronic MRCP is preferred to ERCP in pts with bile duct obstruction due to chronic pancreatitis and in pts in whom ERCP was unsuccessfulpancreatitis and in pts in whom ERCP was unsuccessful

Thrombosis in cancerThrombosis in cancer Cancer causes a hypercoagulable stateCancer causes a hypercoagulable state

Cancer pts often have multiple comorbidities as well, Cancer pts often have multiple comorbidities as well, including hospitalizations, immobilization, surgery, advanced including hospitalizations, immobilization, surgery, advanced age, metastatic disease, presence of a central venous catheter, age, metastatic disease, presence of a central venous catheter, and chemotherapy (including gemcitabine as in this patient)and chemotherapy (including gemcitabine as in this patient)

Thrombotic episodes may precede the dx of Thrombotic episodes may precede the dx of malignancy by months or yearsmalignancy by months or years Particularly true for carcinomas of the GI tract, ovaries, Particularly true for carcinomas of the GI tract, ovaries,

prostate, and lungprostate, and lung Can present in many different ways, including Trousseau’s Can present in many different ways, including Trousseau’s

syndrome, idiopathic DVT, nonbacterial thrombotic syndrome, idiopathic DVT, nonbacterial thrombotic endocarditis, DIC, thrombotic microangiopathy (i.e. hemolytic-endocarditis, DIC, thrombotic microangiopathy (i.e. hemolytic-uremic syndrome), or arterial thrombosisuremic syndrome), or arterial thrombosis

Clinical thromboembolism is the second leading cause Clinical thromboembolism is the second leading cause of death in pts with overt malignant diseaseof death in pts with overt malignant disease In one study, 30% of pts who died of pancreatic cancer had In one study, 30% of pts who died of pancreatic cancer had

evidence of thrombosis evidence of thrombosis 50% of pts with pancreatic cancer in the body or tail had 50% of pts with pancreatic cancer in the body or tail had

evidence of thrombosisevidence of thrombosis

Thrombosis in cancerThrombosis in cancer Trousseau’s syndrome (migratory superficial Trousseau’s syndrome (migratory superficial

thrombophlebitis)thrombophlebitis) Rare variant of venous thrombosis characterized by a Rare variant of venous thrombosis characterized by a

recurrent and migratory pattern and involvement of recurrent and migratory pattern and involvement of superficial veins, frequently in unusual sites such as the arm superficial veins, frequently in unusual sites such as the arm or chestor chest

The pt usually has an occult tumor which is not always The pt usually has an occult tumor which is not always detectable at the time of presentationdetectable at the time of presentation

The tumor us usually an adenocarcinoma when discoveredThe tumor us usually an adenocarcinoma when discovered Most common tumors in pts with this syndrome are pancreas Most common tumors in pts with this syndrome are pancreas

(24%), lung (20%), prostate, stomach, acute leukemia, and colon(24%), lung (20%), prostate, stomach, acute leukemia, and colon Treatment is difficult because Coumadin appears to have no Treatment is difficult because Coumadin appears to have no

effect, while heparin can relieve some of the manifestationseffect, while heparin can relieve some of the manifestations Venous thromboembolism riskVenous thromboembolism risk

Increased in pts with malignancy, particularly with distant Increased in pts with malignancy, particularly with distant metastasesmetastases

Highest risk in pts with hematologic malignancies, lung, GI Highest risk in pts with hematologic malignancies, lung, GI tract, brain, kidney, and breast cancerstract, brain, kidney, and breast cancers

Risk is highest in the first 3 months following a dx of Risk is highest in the first 3 months following a dx of malignancy and decreases after that period of timemalignancy and decreases after that period of time

VTE at least one year after the dx of a malignancy may VTE at least one year after the dx of a malignancy may indicate a second malignancyindicate a second malignancy

What to do?What to do?

There is an absence of prospective studies There is an absence of prospective studies demonstrating cost-effectiveness or improved demonstrating cost-effectiveness or improved survival with aggressive diagnostic testing for survival with aggressive diagnostic testing for malignancy in patients with idiopathic DVT’smalignancy in patients with idiopathic DVT’s Therefore, at this time, only a careful history, Therefore, at this time, only a careful history,

physical exam (including rectal and pelvic exams), physical exam (including rectal and pelvic exams), and routine lab testing (i.e. CBC, lytes, calcium and routine lab testing (i.e. CBC, lytes, calcium creatinine, LFT’s, UA, chest radiograph, and PSA creatinine, LFT’s, UA, chest radiograph, and PSA in men over age 50) should be performedin men over age 50) should be performed

Any abnormalities on these tests should then be Any abnormalities on these tests should then be more thoroughly evaluatedmore thoroughly evaluated

However, pts who present with recurrent However, pts who present with recurrent idiopathic DVT’s represent a high-risk group idiopathic DVT’s represent a high-risk group and an aggressive search for malignancy and an aggressive search for malignancy should be undertaken in these patientsshould be undertaken in these patients

ReferencesReferences

UpToDate; all accessed 1/26/09UpToDate; all accessed 1/26/09 Bauer, K. Drug-induced thrombosis Bauer, K. Drug-induced thrombosis

and vascular disease in patients with and vascular disease in patients with malignancy.malignancy.

Bauer, K. Hypercoagulable disorders Bauer, K. Hypercoagulable disorders associated with malignancy.associated with malignancy.

Steer, M. Clinical manifestations, Steer, M. Clinical manifestations, diagnosis, and surgical staging of diagnosis, and surgical staging of exocrine pancreatic cancer.exocrine pancreatic cancer.