Inpatient / hematology and oncology
New Pancreatic Mass
# Pancreatic Mass
Checklist
-- ABCs: assess for life-threatening disease such as PE/DVT or sepsis/cholangitis
-- HPI Intake: smoking, EtoH use, poor appetite, weight loss, RUQ pain, pale stool, dark urine, FHx cancer
-- Admission Orders: CTAP with IV contrast, CBC, BMP, LFTs, lipase, CA 19-9, CEA
Assessment:
-- History: *** smoking, EtoH use, diabetes, chronic pancreatitis
-- Clinical: *** poor appetite, weight loss, RUQ/epigastric pain, pale stool, dark urine
-- Exam: *** jaundice, cachexia, ascites, distention, LE edema, Courvoisier Sign, Trousseau Syndrome
-- Data: *** LFTs, lipase, CA 19-9, CEA, CTAP
-- Etiology/DDx: *** adenocarcinoma, neuroendocrine tumor, IPMN, pseudocyst, metastasis
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- f/u CBC, BMP, LFTs, lipase, CA 19-9, CEA
-- Imaging: *** CTAP with IV contrast vs RUQUS → MRI/MRCP to further characterize; CT chest to stage if ultimately cancer
-- Biopsy: *** GI vs IR for EUS, ERCP, or biopsy of metastasis
Treatment
-- Pancreatic Adenocarcinoma: in outpatient setting - Resectable - surgery (Whipple) and systemic therapy with FOLFIRINOX; Locally Advanced - FOLFIRINOX or SBRT; Metastatic - FOLFIRINOX; olaparib for BRCA; MSI-H - pembrolizumab
-- Palliative: *** (pain, N/V, mood, etc)
-- Stenting with GI via ERCP for malignat obstruction
-- Consult Oncology to assist with guidance and arranging follow up
-- Consider an early palliative consult
-- Consider nutrition consult for counseling and supplementation
PDF coming soon!
If You Remember Nothing Else
When patients present with a new pancreatic mass, it is most often a pancreatic adenocarcinoma. More than half of of patients present with metastatic disease. You need to get tissue and stage the tumor before arranging for follow up in the outpatient setting. These patients are at increased risk of biliary obstruction (and thus cholangitis), and clotting.
Clinical Pearls
- Risk factors for pancreatic cancer include smoking, alcohol use obesity, chronic pancreatitis, HNPCC, BRCA
- A majority of pancreatic malignancies are located in the head of the pancreas and come from epithelial cells in acini and ducts (adenocarcinoma); endocrine tumors come from islet cells
- 52% of patients have metastatic disease at diagnosis - liver is most common, followed by lung and peritoneum
- Pancreatic cancer has a 10% 5-year survival rate; 3% for metastatic disease; median survival with successful resection is 18 months
- High risk for infections due to propensity for pancreatic masses to obstruct ducts, leading to cholangitis and often requiring stenting
- Obstruction will often to a cholestatic pattern of LFT elevation
- Double duct sign - dilation of the common bile duct and pancreatic duct due to the tumor in the pancreatic head blocking drainage
- Biopsy of possible mets to liver or peritoneal space often preferred to confirm metastatic spread and assist with staging and treatment planning
- CA 19-9 and CEA are non-specific tumor markers not routinely used, but levels >500 suggest worse outcomes after surgery, and >1000 suggest metastatic disease
- FOLFIRINOX is 5-fluorouracil, leucovorin, irinotecan, oxaliplatin
- Courvoisier sign - painless, enlarged gallbladder with jaundice
- Trousseau Syndrome - superficial thrombophlebitis (10% of cases)
- Necrolytic Migratory Erythema - A cutaneous paraneoplastic skin finding that is typically associated with glucagonoma; characterized by multiple, centrifugally spreading erythematous lesions, especially, on the face, perineum, buttocks, and lower extremities
Trials and Literature
- PRODIGE 4 ACCORD 11 - FOLFIRINOX vs gemcitabine alone in metastatic pancreatic adenocarcinoma - OS 11.1 months vs 6.8 months, but more toxic - neutropenia, diarrhea, neuropathy, yet QOL better; only included ECOG 0-1 and <75 years old; Criticism - trial not blinded, only French population, fit population ECOG 0-1 (NEJM, 2011)
Other Resources
- Clinical Problem Solvers - CPS Schema Pancreatic Mass
