What to do and not do before seeking surgical consultation for a patient with suspected pancreatic cancer

Transcription

1 What to do and not do before seeking surgical consultation for a patient with suspected pancreatic cancer 9 Th Annual Symposium on Gastrointestinal Cancers, St. Louis University School of Medicine Carlos Fernández-del Castillo Director, Pancreas and Biliary Surgery Program, MGH Professor of Surgery, Harvard Medical School

2 Scenario # 1 57 year old woman, developed diabetes 3 months ago, well-controlled with metmorfin, now presents with painless jaundice and 15 lb weight loss. Bilirrubin 10/6.8; CA CT: 2 cm pancreatic head mass; no liver mets; tumor impinges, but does not appear to involve the SMV

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4 Should this patient get an MRI and/or a PET/CT? Should I send this patient for ERCP and stent placement? Should I drain her percutaneously? Does the patient need EUS and biopsy? Does she need CT-guided biopsy? Should I send her to our local general surgeon?

5 Should this patient get an MRI and/or a PET/CT? NO Should I send this patient for ERCP and stent placement? Should I drain her percutaneously? Does the patient need EUS and biopsy? Does she need CT-guided biopsy? Should I send her to our local general surgeon?

6 Preoperative biliary drainage in patients with pancreatic cancer Endoscopic approach always preferred Some retrospective studies have shown increased surgical complications with preop drainage, but others have not. Recent RCT shows no difference in mortality, but increased complications (stent occlusion, pancreatitis);? Applicable to care in US. Bottom line: Unless patient will be seen by surgeon without delay (and he/she is taking patient to surgery relatively soon), you should proceed with stenting.

7 Is EUS or CT-guided biopsy necessary prior to proceeding with surgery? NO, unless Patient is getting neoadjuvant treatment as part of a protocol or because he is borderline resectable Radiologic features suggestive of lymphoma or AIP, or very atypical for ductal adenoca. EUS preferred to CT for obtention of tissue Always remember a negative biopsy does not rule out cancer!

8 WHIPPLE RESECTIONS AT MGH (n = 136) JAN 1, 2009 DEC 31, 2009

9 Autoimmune Pancreatitis The great simulator Presence of typical radiologic features is helpful, but they are not always present Suspect in patients with other autoimmune diseases or IBD Measure IgG4, Helpful to get surgeon involved if you will give steroids as a trial

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11 Treatment Prednisone 40 mg po qd initiated Repeat CT scan and ERCP performed at 3 weeks to confirm response Minor ductal irregularities persist but overall much improved, and consistent with a dx of AIP

12 Final post-treatment ERCP Prednisone 40 mg/d x 4 weeks Slow taper to 0 mg/day over 4 more weeks LFTs are normal Pt feels well Monitor IgG4 (was 213 mg/dl at end of Rx) LFTs 3 3mos Duct morphology now normal!

13 Pancreatic Lymphoma

14 Acinar Cell Carcinoma

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16 Where should this patient have surgery? Current operative mortality for Whipple procedure is <3% is specialized centers, but complications occur in >40%. Many studies have shown an inverse correlation between hospital and surgeon volume with mortality for PD. Long-term outcomes are also better when surgery done by high-volume providers.

17 Volume of Pancreatic Resection and Operative Mortality In-hospital moratlity rates as function of volume; n=7,558 pts. Meguid et al, JACS 2008; 206:622-8

18 Not infrequently, patients with radiographically resectable pancreatic cancer are explored by an inexperienced surgeon who finds the tumor inoperable, or attempts to obtain intraop tissue diagnosis without success, and then performs a surgical biliary bypass.

19 Scenario # 2 76 year old woman, 60 PPY smoking, has a 5 month history of epigastric pain; workup 3 months ago was non-revealing. 20 lb weight loss; pain has become worse. New CT: 4.5 cm in tail of the pancreas, adjacent to spleen, appears resectable, no obvious metastatic spread. CA 19-9: 380

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22 Laparoscopy for Staging in Pancreatic Cancer Laparoscopy can identify peritoneal and liver implants in patients with pancreatic cancer with no metastatic spread visible by CT, MRI, or US Yield is higher in cancers of the distal pancreas (46%), and less in tumors of the head (10-18%). Operative skill for laparoscopy is minimal, and within reach of surgeon who does laparoscopic cholecystectomy

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25 Scenario # 3 62 year old man, known gallstones (asymptomatic), HTN, presents with painless jaundice. Bilirrubin 6.4/4.0; CA 19-9: 58 CT: dilation of intra-and extrahepatic biliary ducts; no pancreatic mass seen.

26 Differential dx much broader, and includes non-malignant causes This patient may benefit from an MRCP ERCP and EUS are critical for diagnostic work-up Referral to surgeon comes later, often with a definitive diagnosis or if diagnostic dilemma continues.

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