Abdominal discomfort, loss of appetite, weight lost, weakness and occasional nausea.

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.

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Sample Answer

 

 

J.C.’s Pancreatic Cancer Case Study

1. Potential Metastasis Sites:

The most common sites for metastasis (spread) of pancreatic cancer are:

  • Liver: The liver receives blood directly from the pancreas through the portal vein, making it a prime target for cancer cells to travel and establish secondary tumors.
  • Peritoneum: This is the lining of the abdominal cavity. Pancreatic cancer cells can directly invade the peritoneum or spread through fluids in the abdomen.
  • Lungs: Cancer cells can travel through the bloodstream and reach the lungs, where they can form secondary tumors.
  • Lymph Nodes: These are small organs that filter lymph fluid, which contains immune cells. Pancreatic cancer can spread to nearby lymph nodes first before traveling to other organs.

Full Answer Section

 

 

 

Tumor Cell Markers:

Tumor markers are substances produced by some cancer cells that can be detected in the blood. They are not definitive for diagnosing cancer, but they can be used to:

  • Monitor treatment:A rise in tumor markers after treatment might indicate the cancer is not responding well.
  • Detect recurrence:Elevated tumor markers after successful treatment could suggest cancer has returned.
  • Guide treatment decisions:Certain tumor markers might be useful in selecting specific treatment options.

Pancreatic cancer doesn’t have a single, reliable tumor marker. However, doctors might order tests for CA 19-9, CEA (carcinoembryonic antigen), and CA-242 in some cases.

  1. TNM Staging:

Based on the information provided, the TNM staging for J.C.’s cancer can’t be definitively confirmed. However, some possibilities can be inferred:

  • T:The tumor size (4 cm) suggests T3 (tumor larger than 3 cm).
  • N:The presence of a 1.5 cm lymph node suggests possible N1 (positive regional lymph node involvement).
  • M:We don’t have information about distant metastasis, but the suspicion of infiltration into the superior mesenteric vein raises concern for potential future distant spread (M1).

Importance of TNM Staging:

TNM staging is a standardized system that classifies cancer based on the size and location of the primary tumor (T), involvement of lymph nodes (N), and presence of distant metastasis (M). This staging system helps determine the severity of the cancer, guide treatment recommendations, and predict prognosis.

  1. Characteristics of Malignant Tumors:

Malignant tumors are characterized by abnormal cell growth and behavior:

  • Uncontrolled Cell Division:Cancer cells divide rapidly and uncontrollably, forming masses or tumors.
  • Invasion:Cancer cells can invade surrounding healthy tissues, disrupting their function.
  • Metastasis:Cancer cells can detach from the primary tumor, travel through the bloodstream or lymphatic system, and establish secondary tumors in other organs.
  1. Carcinogenesis Phase of Metastasis:

Metastasis is the final stage of the multistep process of cancer development (carcinogenesis). It involves the following steps:

  • Local Invasion:Cancer cells break through the basement membrane and invade surrounding tissues.
  • Intravasation:Cancer cells enter the bloodstream or lymphatic vessels.
  • Circulation:Cancer cells travel through the bloodstream or lymphatic system.
  • Extravasation:Cancer cells exit the bloodstream or lymphatic system and lodge in a new location.
  • Colonization:Cancer cells establish a blood supply and start growing in the new location, forming a secondary tumor.
  1. Tissue Level Affected:

J.C. most likely has cancer originating in the epithelial tissue. The pancreas contains exocrine tissue that produces digestive enzymes and endocrine tissue that produces hormones. The exocrine portion is composed of epithelial cells lining the ducts and acini responsible for enzyme production. Endoscopic ultrasound and biopsy point towards a tumor in the head of the pancreas, further supporting the epithelial origin.

 

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