Case Presentation for Metastatic Pancreatic Cancer

George Kim, MD:The patient that we’re presented with is a 63-year-old gentleman who presents with the typical symptoms of pancreatic cancer. They’ve had changes in their appetite and weight. They have weight loss and pain, and they also have jaundice. So, it’s a very typical presentation for a pancreas cancer patient.

He presents to his primary physician who works him up. Common things being common—perhaps they’re concerned about reflux, acid disease—but eventually, he works his way to imaging. In this instance, he undergoes an MRI that identifies a tumor in the pancreas. It’s causing symptoms, it’s causing obstruction, that’s why he’s jaundiced. So, that’s where we have our diagnosis. Many times, a CAT scan will be performed. Sometimes a PET scan can be performed in that setting. He also has laboratory studies that are done that reveal abnormalities obviously in his bilirubin, his liver enzymes, and these are important when we start talking about our treatments because many of our treatments have to have good, pristine liver function. His primary physician also sends off for tumor markers, and these are elevated. His CA 19-9 is quite elevated at 12,000 U/mL, which is very concerning for advanced disease. His CEA is also elevated.

So, when we work folks up, again, symptoms and jaundice require further imaging that will probably require endoscopy and endoscopic ultrasound looking at the pancreas and determining whether there’s a mass present. They’ll go on to ERCP (endoscopic retrograde cholangiopancreatography) because this patient is jaundiced and a stent is needed to relieve the obstruction caused by the mass in the pancreas affecting his liver outflow. We need to get him stented and symptoms relieved, and then we can start moving toward discussion with regards to treatment.

The patient presentation is very typical for folks that are diagnosed with metastatic pancreatic cancer. They have pain, they have changes in their appetite, they have abdominal symptoms such as vomiting, nausea, early satiety, cramping, and diarrhea, and our patient also has jaundice. So, again, these are all very common side effects from the cancer. And we really have to do a good job of managing many of these comorbidities or consequences of the tumor in the pancreas.

For this individual, we really want to provide antiemetic support—degassing agents, pain control, monitoring, making sure they’re on good pancreas enzymes allowing them to maximize their intake, their nutrition, and then managing their bile ducts with stenting. This patient is very typical of a person that presents. And overall, his performance status is a 0 to 1, because he does have symptoms relating to his cancer. And so, the patient is one who typically presents in the clinic.

Unfortunately, the scans that were done reveal a mass in the pancreas. We’re also informed that he had metastatic disease, and so we start thinking about palliative approaches to systemic chemotherapy.

Transcript edited for clarity.

March 2016

• A 63-year-old Caucasian male was admitted to the hospital from the emergency room with symptoms of epigastric pain that radiated toward the back, abdominal distention, vomiting, and jaundice
• Laboratory tests:
  • Bilirubin and liver enzymes; elevated
  • CBC values WNL
  • Hepatitis B, & C testing, negative
  • CEA: 34.2 ng/mL; CA 19-9 > 12000 U/mL
• Performance status, 1
• CT reveals 3.5 cm × 3.7 cm mass in the head of the pancreas and multiple liver nodules; also, indicates an obstruction of the bile duct
• Ultrasound-guided percutaneous needle biopsy of a liver metastases shows adenocarcinoma histology
• The patient undergoes biliary stent placement based on endoscopic retrograde cholangiopancreatogram (ERCP) findings
• Diagnosis: stage IV pancreatic cancer with liver metastasis
• The patient was started with treatment on gemcitabine andnab-paclitaxel
• CT with contrast after two treatment cycles showed marked shrinkage of the pancreatic lesion and liver nodules.
• CT after 6 cycles showed stable disease

November 2016

• The patient reports symptoms of rapid weight loss, abdominal pain, dark urine, and jaundice; he has declining functional status and is often bedridden
• Systemic therapy is under consideration