Pancreatic Cancer Case

June 9, 2011

An elderly patient is diagnosed with pancreatic cancer. What's your opinion on the case?

History 

Age / gender:  80 , female
Original complaint:  dyspepsia 
 

The patient’s complaints started in February 2010 as dyspepsia, floating digestion problems.  The blood tests were normal, including liver function, CBC and ESR . An endoscopy was performed revealing an antral gastritis. Since the patient’s complaints continued, further investigation started on June 2010.

Pancreas cancer at the head of the pancreas was diagnosed.

The CA 19- 9 was  ‘’459’’  before the surgery when the disease  first diagnosed.

The patient’s history by date is as follows:

13 / 7 / 2010 …Abdominal MR:  tumor in the head of the pancreas  (please find the MRs on the link)

17 / 7 / 2010…..PET-CT:  tumor in the head of the pancreas

22 / 7 / 2010… Abdominal arteriography and portography:

28 / 7 / 2010….  Surgery : total pancreatectomy+splenectomy + Portal vein resection + end-to-end amnastomosis and feeding jejunostomy

14 / 9 / 2010 – 28 / 10 / 2010: IMRT  ( 30 fractions) with 4 cycles adjuvant gemcitabine treatment  ( once a week during radiotherapy treatment  800 mg/m2 IV)

24 / 1 / 2011- 18 / 4 2011 …… 9 cycles of capecitabine treatment (1000mg/m2)

After the radiotherapy treatment, the patient started to receive chemotherapy with gemcitabine (a total of 9 cycles) at a dose of 1000 mg / m2 IV . She received the chemotherapy on  24 /1/2011, 31/1/2011, 14/2/2011, 21/2/2011, 7/3/2011, 14/3/2011, 28/3/2011, 4/4/2011 and 18/4/2011 respectively.

Blood levels of  CA 19-9 by date: 
13.07.2010 - 459
15.07.2010 - 726
01.09.2010 - 83
16.09.2010 - 109
08.11.2010 - 1631
22.11.2010 - 3978
06.12.2010 - 3459
21.12.2010 - 2395
06.01.2011 2274
24.01.2011 - 2150
31.01.2011 - 1730
14.02.2011 - 1952
21.02.2011 - 1375
28.02.2011 - 1457
07.03.2011 - 1263
14.03.2011 - 1451
02.04.2011 - 2218
16.04.2011 - 2665
30.04.2011 - 4929
23.05.2011 - 7018

The abdominal MR (May 2011) performed sequentially with the raise in the tumor marker showed no metastasis, but the PET-CT (also performed May  2011) showed suspected lesions on the peritoneum as lymph nodes. But the liver and local operation area was free of disease. 

The complete PET-CT findings:

"There is an irregularly shaped mass lesion measured 23×16 mm in diameter, located at head of the pancreas, with increased FDG accumulation (SUVmax=11.7, SUVmean=7.3, vol=8.8 cm3). No other pathological FDG accumulation is determined in the other abdominopelvic organs and lymphatic stations. The hypodense lesion located subcapsularly in the 7th segment of the right lobe of the liver showed no visible FDG accumulation. 

No pathological FDG accumulation is seen at the lung parenchyma and mediastinal lymphatic stations.

Physiological FDG distribution is noticed at the skullbase and cervical lymphatic chains.

Multinodular hyperplasia showing no FDG accumulation is seen at the right lobe of the thyroid gland, which extends through thoracic inlet and shows some calcifications.

Cerebral and cerebellar hemispheres demonstrated a physiological and symmetrical FDG distribution. Subcortical structures are in normal appearance."
 

Since CA 19-9 started to raise again under gemcitabine therapy, the treatment  was switched to  capecitabine orally 2000mg/day on May 5, 2011. The patient received the treatment for 14 days between May 5, 2011 and May 19, 2011, but the tumor marker continued to raise as you will see on the chart.

She started to take the second cycle of capecitabine treatment  starting on May 27, 2011.