Week 6 | Harry Peng | Dr. Rohit Chandwani

This week I again shadowed Dr. Chandwani in his clinic, mostly follow-up cases. Some patients had the procedure years ago, while others weeks ago.

Patients will undergo continuous monitoring of food intake, bowel movement, weight loss, and metabolic panel. Specimens (tumor) taken out during the surgery will generally be delivered to the pathology lab for genetic testing. Normally the tumor is tested positively malignant just as expected, and the specimen margin is negative to ensure the total removal of the tumor. One patient had a very rare mutation in PDAC that was not even found in the database. The pancreatic ductal cells had an ERCC3 and BRAF mutation. Only 10% of PDAC are not KRAS mutation.

More complicated and uncertain cases require continuous monitoring of the development at the suspicious site. One patient at the age of 88 was diagnosed of gall bladder cancer and adrenal carcinoma four years ago. Part of the lowest rib had to be removed because the cancer had metastasized to the intercostal muscle in the chest. The patient has no muscle in the abdomen, experiencing hernia (when an internal organ pushes through a weak spot in your muscle or tissue). The hernia is causing pain and there is also a small mass in the abdomen growing slowly. Since the mass is growing so slow and is not affecting the surrounding organs, the patient was not recommended surgery considering the age and the burden of the procedure.

This week's conflict in surgical decisions continuously lies between imaging and biopsy. Many times the oncologist is not able to accurately describe the pathology from the imaging. The biopsy also has a high false negative rate when the malignant tissue is small and hard to reach. Therefore, the patient will be asked either to have the surgery right away without a second biopsy or to have more MRI or CT scans in the near future. This depends on how serious the oncologist considers the case is and whether or not there is any worsening at the suspicious site. For example, if any of the ducts (i.e. bile duct, pancreatic duct) or vessels (i.e. portal vein) keeps enlarging, it is highly likely that there is some kind of mass blocking them. The mass might not be showing clearly in the image due to the small size or resolution of the scan. On the other hand, if the mass (not always cancer) is shrinking over the course of imaging, more conservative treatment will be given; usually, continuously monitoring through MRI or CT scans until the mass is completely gone.