Hi Dr. Please Pass This On To A Oncologist Surgeon

Posted on Mon, 15 Jul 2019

Question: Hi Dr. Please pass this on to a Oncologist Surgeon I want to know your expert observation on this case. Main issue is the big mass of measuring 5.4 cm by 3.6 cm in the pancreas tail. The surgeon says nothing can be done accept to buy him time. I don't believe this is true. This is based on these cat scan results. Cat scan states increases size to the neurotic mass in the region of pancreatic tail is inseparable from and likely involving the adjacent stomach, anterior kidney, adrenal gland, and splenic flexure measuring 5.4 x 3.6 in size. (Additional Information) Also cat scat stated there is a hydro density within the liver adjacent to the IVC new measuring 9mm in size suspicious for metastatic disease. There is another hypodensity measuring 8 mm in size. which could represent metastatic disease. Also, there is retroperitoneal adenopathy which is mild from new from previous examination suspicious for metastatic disease. Last there is a increased right lower lobe nodule a measuring up to 6 mm. (Nano knife technology is in the hospital that his surgeon is in. That doctor perform it. He tell the oncologist that give the patients chemotherapy, I wont do any surgery on this case. There are many great doctor in the United states, but not all. Please share with me you expert opinion. A case of a women in the states had stage 4 pancreas cancer, and a doctor did this Nano knife, and she has be cancer free for 6 years. Sorry to repeat myself, but can surgery be done. Thank you

Follow up: Dr. Bhagyesh V. Patel (0 minute later)

Hi Dr. Please pass this on to a Oncologist Surgeon I want to know your expert observation on this case. Main issue is the big mass of measuring 5.4 cm by 3.6 cm in the pancreas tail. The surgeon says nothing can be done accept to buy him time. I don't believe this is true. This is based on these cat scan results. Cat scan states increases size to the neurotic mass in the region of pancreatic tail is inseparable from and likely involving the adjacent stomach, anterior kidney, adrenal gland, and splenic flexure measuring 5.4 x 3.6 in size. (Additional Information) Also cat scat stated there is a hydro density within the liver adjacent to the IVC new measuring 9mm in size suspicious for metastatic disease. There is another hypodensity measuring 8 mm in size. which could represent metastatic disease. Also, there is retroperitoneal adenopathy which is mild from new from previous examination suspicious for metastatic disease. Last there is a increased right lower lobe nodule a measuring up to 6 mm. (Nano knife technology is in the hospital that his surgeon is in. That doctor perform it. He tell the oncologist that give the patients chemotherapy, I wont do any surgery on this case. There are many great doctor in the United states, but not all. Please share with me you expert opinion. A case of a women in the states had stage 4 pancreas cancer, and a doctor did this Nano knife, and she has be cancer free for 6 years. Sorry to repeat myself, but can surgery be done. Thank you

Answered by Dr. Bhagyesh V. Patel (26 hours later)

Brief Answer:
surgery not recommended, chemo will not help to much extent.

Detailed Answer:
Hello and welcome to Ask A Doctor services.
I have read your query with attached report and here is my advise.

* The report depicting increasing necrotic tissue of pancreas with inseparable growth
involving stomach, kidney, adrenal gland, spleen and retroperitoneal lymph nodes,
liver metastasis indicate the clinical and pathological stage 4 of cancer pancreas.

* Cancer of pancreas is very aggressive and individual decisions have to be figured out
depending upon the particular case details for further management guidelines.

* If one considers management of current case

@ Surgery is out of question as neither it is curative nor it will improve quality of life or
prolong it ; on the reverse one can deteriorate the issue more worse than present
by venturing surgery.
@ Chemotherapy would also be not of much rewarding at this stage as there are
ample of side effects which will over weight than possible benefits for metastasis.

* It is hard to say and sorry to convey you, but my surgical experience narrates that this
patient require tender loving care for rest of the period to have less of the pain and
suffering with family support and adjuvant medical care.

I firmly believe in the quality of life rather than number of years the patient passes
with great pain and discomfort in many cases.

Hope this information will be helpful for you.
Do feel free to discuss further regarding the issue.

Wish him best health ahead.
Regards.

Dr Bhagyesh ( MS consultant surgeon )

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Bhagyesh V. Patel (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Bhagyesh V. Patel (12 hours later)

Hi, thank you for your expertise's. I have a very important question for you. I have send you another Cat scan of abdomen pelvis that was taken on March, 29 2018. The Original Cat Scan I sent you was taken XXXXXXX 10, 2019. ( exactly 73 days later). As you read the Cat Scan on 3.29.2019, you will see results. The impression is written as the following, please read fil cat scan. (New Heterogeneous soft tissue density In the region of the pancreas tail resection which is abutting the Kidney. Recurrence disease or possible pancreatic. The area measures up to 2.6 cm.

The Oncologist told my Uncle, not sure if it is SCAR TISSUE , can't tell, No other test were given. In your expertise's, shouldn't the Oncologist Surgeon given in a pet scan to see exactly what the 2.6 cm was. New Heterogeneous soft tissue density In the region of the pancreas tail resection which is abutting the Kidney.

He told him to come back 3 month later to evaluate. The Oncologist was not concerned about this 2.6 cm in on tail of pancreas. As you see by the 73th day after the cat scan was taken, the results were extremely bad, that it has metastasized to liver, (2 tumor in liver). Also, retroperitoneal adenopathy which is suspicious for metastatic disease best seen in the aortocaval space measuring 9m on short axis. Increases size to the neurotic mass in the region of pancreatic tail is inseparable from and likely involving the adjacent stomach, anterior kidney, adrenal gland, and splenic flexure measuring 5.4 x 3.6 in size. (Grew from 2.6 cm to 5.6 cm.

I need to know this answerer, and anything you can observe from this case. If the Oncologist surgeon carefully followed the cat scan on 3/29/2019 and did a pet scan to rule out was the 2.6 cm was.

If it came back as a cancerous tumor on tail of pancreas tail. and the Oncologist Surgeon told the Oncologist to start chemotherapy right away, couldn't the chemotherapy give him a much better chance of survival to shrink the 2.6 cm soft tissue tumor, and also, the likelihood of it metastasizing to the liver, Hi, thank you for your expertise's. I have a very important question for you. I have send you another Cat scan of abdomen pelvis that was taken on March, 29 2018. The Original Cat Scan I sent you was taken XXXXXXX 10, 2019. ( exactly 73 days later). As you read the Cat Scan on 3.29.2019, you will see results. The impression is written as the following, please read fil cat scan. (New Heterogeneous soft tissue density In the region of the pancreas tail resection which is abutting the Kidney. Recurrence disease or possible pancreatic. The area measures up to 2.6 cm.

The Oncologist told my Uncle, not sure if it is SCAR TISSUE , can't tell, No other test were given. In your expertise's, shouldn't the Oncologist Surgeon given in a pet scan to see exactly what the 2.6 cm was. New Heterogeneous soft tissue density In the region of the pancreas tail resection which is abutting the Kidney.

He told him to come back 3 month later to evaluate. The Oncologist was not concerned about this 2.6 cm in on tail of pancreas. As you see by the 73th day after the cat scan was taken, the results were extremely bad, that it has metastasized to liver, (2 tumor in liver). Also, retroperitoneal adenopathy which is suspicious for metastatic disease best seen in the aortocaval space measuring 9m on short axis. Increases size to the neurotic mass in the region of pancreatic tail is inseparable from and likely involving the adjacent stomach, anterior kidney, adrenal gland, and splenic flexure measuring 5.4 x 3.6 in size. (Grew from 2.6 cm to 5.6 cm.

I need to know this answerer, and anything you can observe from this case. If the Oncologist surgeon carefully followed the cat scan on 3/29/2019 and did a pet scan to rule out was the 2.6 cm was.

If it came back as a cancerous tumor on tail of pancreas tail. and the Oncologist Surgeon told the Oncologist to start chemotherapy right away, couldn't the chemotherapy give him a much better chance of survival to shrink the 2.6 cm soft tissue tumor, and also, the likelihood of it metastasizing to the liver with two tumors measuring both one that was 8mm, and the other which was 8mm, and also to the retroperitoneal adenopathy which measured both up 9mm.

As a expert in your field, if this was you patients you were treating that the cat scan on march 29, 2019, came back with only the 2.6 cm on tail of pancreas. WHAT COURSE OF TRATMENT WOULD YOU HAVE STARTED. My observation is if treatment was started immediately or soon after, his survival rate would of went up a considerable amount. Please give you assessment an expert. I want to thank you very much.

Follow up: Dr. Bhagyesh V. Patel (0 minute later)

Answered by Dr. Bhagyesh V. Patel (1 hour later)

Brief Answer:
follow up .

Detailed Answer:
Hi
Welcome for the follow up.

* As per my surgical experience, the best centers with recurrent pancreatic cancer and
metastasis do show up very poor prognosis after best of the medical therapy though
there can be various courses in terms of outcome, survival rates and other clinical
parameters to varying degree as per the individual case.

* There are very gross and wide variations in individual responses as you can not
compare two similar cases for outcome to same treatment, as body reacts quite
different in terms of immunity and cellular response beyond imagination of an expert
consultant.

* Considering two reports comparison, obviously an expert oncosurgeon would not miss
the gross finding and let your patient suffer in agony for future outcome ; what
matters is what was explained to patient, relatives and what counselling was done at
that time, in terms of diagnosis, mode of action , future outcome in terms of prons and
cons.

* It is the fundamental duty of any consultant to explain the various aspects of reports in
corelation with clinical condition to the patient and with consent of patient to relatives
as what stage the patient has regarding the disease, what modalities are available for
its management, what are its benefits, disadvantages ; what will be benefits and
disadvantages when we opt for not choosing particular therapy for particular reasons.

* When everything is explained, and then any decision is taken for the due course of
action, it is a combined decision of consultant and patient knowing everything ; when
nothing is explained thoroughly then it goes against a consultant ethical practice
standard and there comes mis management of the patient.

* One can not stamp at this stage, that if the chemo was started 73 days before the
second CT , patient must have benefited but yes one can say he may have some
superior outcome if the body responded to therapy at best possible way and on the
reverse - his condition may have deteriorated if the immune cells of body were
destroyed and through tumor lysis syndrome lot many complications including renal
failure and early death may have a worst outcome.

* So far as my course of action is concerned, at time of CT before 73 days, I give option
of chemotherapy to patient and with consent of patient to relatives regarding the
marching ahead for possible benefits against the side effects and other dangers of
chemo.
I also explain the good and bad of not choosing chemo and wait and watch theory
compared to the above.
It is the final decision of patient ( when patient in alert to make decisions : living will,
power of atterny, health care proxy and other options when patient is not in a position
to make sound decisions on his or her own ) after I explain thoroughly everything on
medical grounds for the particular case and therapy plans.

* So if I comprise it in a nutshell, what important is narration of any report to patient,
and to relatives with consent of the patient ; discussing various outcomes, possible
mode of actions and later the choice depends upon the patient side whether to agree
the consultant for such therapy , disagree or opt for second opinion in best health of
the patient.

I know this is much complex issue, but I have tried to figure out in best possible simplest way for our understanding at basic levels.
Wish you a great day.

Regards.
Dr Bhagyesh

Above answer was peer-reviewed by : Dr. Raju A.T