Unresectable Pancreas Tumor with Celiac Trunk Encasement: the Role and Treatment

Consideration of Radiotherapy Case Number: RT2009 - 120(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with unresectable pancreas tumor with celiac trunk encasement; to discuss the role and treatment consideration of radiotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation:

This 63–year-old male patient, 陳 OO, was referred to us for radiotherapy assessment for ‘pancreatic tumor, suspect malignancy’.

S: 1. This patient suffered from upper abdominal discomfort for about 6 months and upper

abdominal pain for about 2-3 months. 2. In 2007/12, he came to LMC for ABD CT and only some abnormal finding on the

pancreas was told. 3. In 2008/03, he came to our hospital for further management, and abdominal sono

reported a 5.5 cm mass over the pancreatic body. 4. On 2008/03/12, you visited this patient and his wife in the ward. Histories: NDKA, no major medical disease history Review of systems: body weight loss in recent months, poor appetite, soreness of the frank

and the back O:

1. General Condition: ECOG: 1, ambulatory status, sitting on the bed, speech: OK 2. Physical Examinations:

(1). HEENT & SCF: no SCF LNs; (2). CHE: neg.; (3). ABD: mild tenderness over the upper abdominal region; (4). Back & Spine: no knocking pain over the back and spine; (5). Extremities: free movement; (6). Others: neg.

3. ***Pathology: no definitive pathology report for the pancreatic mass. 4. Images:

(1). MRI of the brain in 2008/03: neg. (2). CXR in 2008/03: neg. (3). ABD sono in 2008/03: a 5.5*5.0 cm mass over the pancreatic body (4). ABD CT in 2008/03: a 5.6*5.0 cm mass over the pancreatic body with encasement of the celiac trunk, unresectable disease status; some small Lns over the peri-tumor region, size all less than 1 cm.

5. Others: colon biopsy in 2008/03: tubular adenoma; CEA in 2008/03: 26.9; CA-199: pending result now

Key Image(s): Fig. 1.

Fig. 2.

Fig. 3.

Questions & Discussions: (Please answer the following questions commented from your RT attending

physician.)

Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this

case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for

this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case?

(Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending

physician.)

Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this

case? A2: clinical stage under clinical diagnosis only; strongly suggest histological diagnosis:

cT4(unresectable; celiac trunk encasement)N1M0, stage III (2008/03, AJCC 2002) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for

this case? A3: no pathology stage can be defined in this case. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Oncology Diagnosis: Pancreatic body tumor (5.6*5.0 cm, CEA: 26.9, CA-199 pending,

encasement of celiac trunk, unresectable disease status), suspect malignancy, cT4(unresectable; celiac trunk encasement)N1M0, stage III (2008/03, AJCC 2002)

Q5: What is your Oncology Plan for this case? A5: Suggest Current Oncology Plan:

(1). Further work-up studies: strongly suggest biopsy for histological diagnosis (2). Further treatments: definitive chemotherapy and radiotherapy after tissue proven

Q6: What is your Radiotherapy Plan for this case?

(Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

A6: RT Plan may be designed as the following one: (1). Indication: RT is indicated for this patient after further tissue proven. If no any tissue proven can be obtained, RT may be indicated under currently clinical diagnosis after the patient and family agreed. (2). Goal: curative to potentially curative (3). Target & Volume: pancreatic mass with limited LN-drainage region (4). Technique: 3DCRT (5). Dose & Fractionation: 3960 cGy in 22 fractions to the initial large field then cone-down boost to gross tumor only up to total dose of 5040 cGy in 28 fractions.

Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006

Radiation Oncologist Hon-Yi Lin 2009/04/26

Key Image(s): (with marked) Fig. 1.

Fig. 2.

Fig. 3.

Fig. 2. The pancreas tumor with encasement of main vessels was noted (as the white arrows); a small tumor over the peri-pancreas region with size less than 1 cm was noted (as the white arrow head).

Fig. 3. The pancreas tumor with encasement of main vessels was noted (as the white arrows).

Fig. 1. The pancreas tumor with encasement of main vessels was noted (as the white arrows).