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
Tumor Cell Markers and their Purpose:
- Tumor cell markers are substances produced by certain cancer cells or by the body in response to cancer.
- They are not definitive for diagnosing cancer, but they can be used to:
- Aid Diagnosis: Elevated levels of certain markers may suggest cancer, prompting further investigation.
- Monitor Treatment: Markers can help track the effectiveness of treatment by monitoring if their levels go down.
- Detect Recurrence: Rising marker levels after treatment could indicate cancer recurrence.
3. TNM Staging Classification for J.C.'s Tumor:
Unfortunately, with the information provided, definitively assigning a TNM stage is not possible. However, we can make some educated guesses:
- T: Based on the size (4cm) and infiltration of surrounding structures (Wirsung duct and superior mesenteric vein), the tumor is likely a T3 or T4.
- N: The presence of a metastatic lymph node suggests at least N1.
- M: We don't have confirmation of distant metastasis, so M would be M0 for now.
Importance of TNM Staging:
The TNM classification system is crucial because it categorizes cancer based on:
- T - Tumor size and local invasion
- N - Lymph node involvement
- M - Presence of distant metastasis
This staging helps determine the severity of the cancer and guides treatment decisions, prognosis, and potential outcomes.
4. Characteristics of Malignant Tumors:
- Abnormal Cells: Malignant tumor cells have abnormal characteristics in their growth, appearance, and behavior compared to healthy cells.
- Uncontrolled Growth: They divide rapidly and uncontrollably, forming a mass (tumor).
- Invasion: They can invade surrounding tissues and disrupt their normal function.
- Metastasis: They have the ability to detach, travel through the bloodstream or lymphatic system, and establish new tumors in distant organs.
5. Carcinogenesis Phase During Metastasis:
Metastasis is the final stage of the multistep process of cancer development (carcinogenesis). Here's a simplified breakdown:
- Initiation: DNA damage occurs in a cell.
- Promotion: The damaged cell continues to divide despite abnormalities.
- Progression: The cell acquires additional mutations, becoming more aggressive.
- Metastasis: Cancer cells detach from the primary tumor, invade surrounding tissues, and travel to form new tumors in distant organs.
6. Tissue Level Affected in J.C.: Epithelial
J.C.'s diagnosis is ductal adenocarcinoma of the pancreas. Adenocarcinoma refers to cancer arising from epithelial tissue. The pancreas contains epithelial tissue that lines the ducts responsible for enzyme secretion. Therefore, the cancer originates from the epithelial layer of the pancreas.