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Pancreatic cancer case study

J.C is an 82-year-old white man who was evaluated by GI specialist due to abdominal discomfort, loss of appetite, weight lost, weakness and occasional nausea.

Past Medical History (PMH):
Patient is Diabetic, controlled with Metformin 500 mg by mouth twice a day, Lantus 15 units SC bedtime. Hypertensive, controlled with Olmesartan 20 mg by mouth once a day. Atrial Fibrillation, controlled with Rivaroxaban 15 mg by mouth once a day and bisoprolol 10 mg by mouth once a day.

Labs:
Hb 12.7 g/dl; Hct 38.8% WBC 8.2; Glycemia 74mg/dl; Creatinine 0.8 mg/dl; BUN 9.8 mg/dl; AST 21 U/L ALT 17 U/L; Bil T 1.90 mg/dl; Ind 0.69 mg/dl; Dir 1.21 mg/dl.

Diagnostic test:
Endoscopic Ultrasound of the Pancreas. Solid mass in the head of pancreas 4 cms, infiltrating Wirsung duct. The solid mass impress to infiltrate the superior mesenteric vein. Perilesional node is detected, 1.5 cms, metastatic aspect. Fine needle aspiration (FNA) biopsy: Ductal adenocarcinoma.

Case study questions:

Please name the potential most common sites for metastasis on J.C and why?
What are tumor cell markers and why tumor cell markers are ordered for a patient with pancreatic cancer?
Based on the case study described, proceed to classify the tumor based on the TNM Stage classification. Why this classification important?
Discussed characteristic of malignant tumors regarding it cells, growth and ability to spread.
Describe the carcinogenesis phase when a tumor metastasizes.
Choose the tissue level that is affected on the patient discussed above: Epithelial, Connective, Muscle or Neural. Support your answer.

Full Answer Section

Lymph Nodes:
- Regional lymph node involvement is common, as evidenced by the perilesional node in J.C.'s case. Distant lymph node metastasis can also occur.
Bones:
- While less common, pancreatic cancer can metastasize to bones, causing pain and fractures.

2. Tumor Cell Markers:

Definition:
- Tumor cell markers are substances produced by cancer cells or by the body in response to cancer. They can be found in the blood, urine, or other body fluids.
Importance in Pancreatic Cancer:
- CA 19-9: This is the most common tumor marker used for pancreatic cancer. It can help in diagnosis, monitoring treatment response, and detecting recurrence.
- CEA (Carcinoembryonic Antigen): While less specific, CEA can also be elevated in pancreatic cancer.
- These markers help to:
  - Aid in diagnosis, especially when combined with imaging and biopsy.
  - Monitor the effectiveness of treatment.
  - Detect recurrence after treatment.
  - Help with prognosis.

3. TNM Staging:

T (Tumor):
- T3: Tumor infiltrates the superior mesenteric vein.
N (Nodes):
- N1: Regional lymph node metastasis (perilesional node).
M (Metastasis):
- Because there is a perilesional node that is metastatic, and the tumor is infiltrating the superior mesenteric vein, this would be at least stage 3, and possibly stage 4.
Importance of TNM Classification:
- Provides a standardized system for describing the extent of cancer.
- Helps in determining prognosis.
- Guides treatment decisions.
- Facilitates communication among healthcare professionals.
- It is used to determine if a patient is a candidate for surgery.

4. Characteristics of Malignant Tumors:

Cells:
- Undifferentiated (anaplastic) cells.
- Variations in cell size and shape (pleomorphism).
- Abnormal nuclei.
- Loss of normal cell function.
Growth:
- Uncontrolled and rapid growth.
- Invasion of surrounding tissues.
- Lack of contact inhibition.
Spread:
- Metastasis (spread to distant sites).
- Angiogenesis (formation of new blood vessels to support tumor growth).
- Can spread via the blood stream, and lymphatic system.

5. Carcinogenesis Phase of Metastasis:

Detachment:
- Cancer cells detach from the primary tumor.
Invasion:
- Cancer cells invade surrounding tissues and penetrate blood or lymphatic vessels.
Dissemination:
- Cancer cells travel through the bloodstream or lymphatic system to distant sites.
Establishment:
- Cancer cells adhere to and invade new tissues, forming secondary tumors.
Angiogenesis:
- The new tumor mass stimulates the growth of new blood vessels to supply the tumor with oxygen and nutrients.

6. Tissue Level Affected:

Epithelial Tissue:
- Ductal adenocarcinoma arises from the epithelial cells lining the pancreatic ducts.
- Adenocarcinoma is a type of cancer that originates in glandular epithelial tissue.
- Therefore the epithelial tissue is the primary affected tissue.

Sample Answer

Potential Metastasis Sites and Why:

Liver:
- The liver is a common site for pancreatic cancer metastasis due to its proximity and extensive blood supply. Cancer cells can easily travel through the portal vein to the liver.
Lungs:
- Pancreatic cancer can metastasize to the lungs through the bloodstream or lymphatic system.
Peritoneum:
- Pancreatic cancer can spread to the peritoneum (the lining of the abdominal cavity), leading to peritoneal carcinomatosis.