Unresectable Metastatic Pancreatic Cancer: A Case Review

George Kim, MD:The patient is a 57-year-old gentleman who presents with symptoms of weight loss and pain. They have a smoking history, and they also have a recent history of a blood clot. There is also some family history that we want to explore. Those are some of the features of the patient that you take into consideration when evaluating them and then trying to decide what treatments are available. This individual undergoes further evaluation with imaging, revealing a mass in the pancreas head, and liver lesions. Also, the CA19-9 is quite elevated, roughly 2000 U/mL or higher. He has a performance status of 1 because of the symptoms that are related; the pain and the weight loss.

These are all considerations in deciding what treatments are appropriate. In this situation, what we always want to do is optimize the patient’s performance status; make sure their nutritional status is improved because we know that this gentleman is losing weight. We want to know why. Is it because he has no appetite? Is it because he’s worried that he’s having diarrhea due to pancreas insufficiency? Does he have an intestinal obstruction? We also, in this situation, want to make sure that his bile duct functions are appropriate, his pain control is adequate, and that his glucose levels are also being managed. This gentleman did have a blood clot, 8 months prior to presentation. I worry about this all the time when I see patients newly diagnosed with blood clots, and we put them on anticoagulation for a set period of time. We always worry about what may happen in the future, whether this was a premonition of a later diagnosis of cancer, so that’s very important.

The other background characteristic of this patient is that they smoked tobacco for 35 years, and they quit 5 years prior to presentation. This is really a public service announcement that tobacco use, they say if you stop for 12 years, your risk goes down. I still worry about the future risks for cancer in anybody who has smoked for a prolonged period, 10 years or so. The message here is we really have to do a better job of getting people to stop smoking early, or to not even start smoking. Those are the characteristics of this case that are important. The other one is that the father passed away from a myocardial infarction. We don’t know if this was early on in his life, for example, that he died in his 40s. He didn’t have an opportunity or the life span to develop a cancer, so we don’t fully know the patient’s family history. That is also in the background to be considered.

We conclude that the patient has a diagnosis of metastatic pancreatic cancer. As noted, he has a very good performance status or one that can be managed, and we embark upon visiting with the patient and deciding what treatments are available.

The patient is not a surgical candidate because imaging reveals they had metastatic disease with lesions in the liver. In addition, the CA19-9 was quite high, it’s over 2000, which portends metastatic disease and also poor prognosis. Remember the lesion is in the head of the pancreas, he would have to undergo a Whipple (pancreaticoduodenectomy) procedure; very challenging then to undergo that surgery, which is a minimal, if at all, benefit and then undergo chemotherapy for metastatic disease. So really, surgery does not have an important role here.

Transcript edited for clarity.

A 57-Year-Old Man With Abdominal Pain and Unexplained Weight Loss

• A 57-year-old man was referred from his primary care clinician with complaints of persistent pain in his upper abdomen that radiate to his back
• History
  • Former smoker (35 years, quit 5 years ago)
  • Was obese (BMI 29.0), but began losing weight despite not changing his eating habits
  • Reports feeling “tired” despite regular sleep habits
  • Treated for DVT 8 months ago
  • Hypertension controlled on medication, impaired glucose tolerance
  • Family history: mother alive with type 2 diabetes, father died (MI)
• Clinical evaluation
  • CT reveals mass in head of pancreas with metastases in liver and blood vessels
  • CA19-9 level: 55 times upper limit of normal
  • ECOG PS: 1
• Diagnosis: unresectable metastatic pancreatic cancer
• Patient began treatment with IV nab-paclitaxel (125 mg/m²) plus IV gemcitabine (1000 mg/m²) on days 1, 8 and 15 of a 28-day cycle
  • Experienced grade 3 neutropenia; did not require growth factors
  • Had mild peripheral neuropathy that did not progress or require dose adjustment
• At 6 months, patient progressed and received second-line treatment with liposomal irinotecan in combination with 5-FU/LV