Week 3 of Summer Immersion - Harry Peng

In this week's clinic, one of the patients whom Dr. Rohit Chandwani operated on 2 weeks ago came back for a follow-up visit. The patient had severe nausea, congestion, and heartburn after the surgery, but the condition has turned much better since last time. The patient could produce 4 to 5 stools per day, meaning a more normal bowel movement. Dr. Chandwani suggested the patient continue taking CREON (pancrelipase), an common enzymatic medication and supplement to help with the digestion of food after removal of pancreas.

The drainage tube was taken out from the abdomen. Normally one liter of fluid is produced per day in the abdominal cavity. Since the patient had only about 100 mL drain, this means that the leakage is controlled. Stitches on the major incision were all removed and strips were put on.

From the pathology report, the patient had T2 (stage 2) malignant pancreatic tumor of 2.5x2x2 cm in size. This is a T2 instead of T1 because 2 out of 33 lymph nodes presented metastasis. This is a relatively low number, which is promising for recovery. There is a benign neuroendocrine tumor (NET) found in one of the lymph nodes. The NET has no clear etiology. Since the patient had lung cancer previously and right lung total removal, a dodecane scan (similar to PET scan) was recommended to check if the NET is originated from the lung cancer from before. Genetic mutation testing was also ongoing on the tumor specimen.

For breast cancer, the oncologist would consider using minimal effective treatment. For example, in the case of a confined tumor with no sign of metastasis, there is no need to remove the whole breast, or the cervical lymph node, which may cause lymphedema. However, this is not the case for pancreatic cancer. Since pancreatic cancer (PC) is so aggressive, always more is better, so the patients are mostly over-treated. Whipple procedure with tumor negative margin requires the removal of the whole pancreas, gall bladder, and part of the small intestine. Multiple adjuvant chemotherapy drugs would be given to the patients as well. The combination of three adjuvant chemos would increase the 5-year OS of PC patients from 10% to 30%, compared to single chemo.

Another patient is the most severe case I have ever seen. The patient had stage 4 PC, with multiple cystic masses in the peritoneal cavity, and metastasized to the liver (3 liver lesions), ovaries, and the fallopian tube. The patient had seen a liver oncologist and a gynecological oncologist, and now a pancreatic oncologist. For a T4 PC patient, there is no benefit to operating on the patient and surgically removing every malignant tumor mass and organ invaded by the tumor if the procedure cannot increase the life span or reduce the pain. A surgical oncologist would rather operate on a T4 (stage 4) colorectal cancer (CRC) patient than a T3 PC patient due to the aggressiveness of the PC.

Among all PC patients, approximately 30% are inoperable due to proximity to major blood vessels, 50% metastasis to other organs/lymph nodes, and 20% operable. Out of 30% inoperable cases, the 5yr OS is 5%; out of 50% metastatic cases, the 5yr OS is 1%; out of 20% operable cases, the 5yr OS is 40%. Adding everything up, the OS of pancreatic cancer is 10%. There is also a 50% of recurrence rate after surgery and chemo for PC.


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