HomeAnswersMedical oncologyperiampullary carcinomaDoes periampullary carcinoma require a PET scan for treatment?

A patient with stomach pain was diagnosed with cancer in FNAC. Does she need a PET scan?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

Dr. Sushrutha M.

Published At July 19, 2021
Reviewed AtJuly 19, 2021

Patient's Query

Hi doctor,

A patient has abdomen pain and vomiting with fever one month back. She was admitted to the hospital and came back home. Again last week, she had pain, and a lot of tests were performed. In which her FNAC reports showed cancer. Based on these reports, we require what should be the following protocol to move further. I am attaching her reports.

1) Whether she requires a small surgery to take out the mass and should be given for final biopsy and IHC?

2) Require a PET scan or direct surgery?

3) Does she require chemotherapy?

Kindly give your opinion.

Hello,

Welcome to icliniq.com.

I have gone through your query and reports provided (attachments are removed to protect the patient's report).

Based on this, my final analysis is periampullary carcinoma, biopsy papillary tubular neoplasm, and MRCP CT (magnetic resonance cholangiopancreatography) is a localized disease that appears resectable.

The best treatment for periampullary carcinomas is surgery followed by chemotherapy. As she had undergone a biopsy and FNAC (fine needle aspiration cytology) additional small operation is not required. Direct chemotherapy is not needed unless the surgeon feels that the tumor is not resectable and needs to be downsized (which does not appear to be the case as per the report).

A PET (positron emission tomography) scan can be done before to check whether the tumor has spread to anywhere else like lungs or bones as these organs are not covered in CT 9computed tomography) well.

Also would like to see her bilirubin levels to see if she needs stenting before surgery to reduce jaundice (if present).

The best case for her would be a PET scan followed by direct surgery.

If you have any more questions, you can always revert back here. I hope this was helpful.

Patient's Query

Hi doctor,

I am attaching here the biopsy reports of a patient who had Whipple surgery in another city.

My queries based on her history and histopathological reports are as follows:

  1. Does the patient require chemotherapy now? If yes then which chemotherapy drugs are useful for the patient?
  2. How many cycles of chemotherapy the patient should take, six cycles?
  3. After chemotherapy when and which investigation is needed?

Hello,

Welcome back to icliniq.com.

Based on the reports provided (attachments removed to protect the patient's identity), the summary is that the patient has stage-2 periampullary carcinoma (T3N0). For which, the patient has undergone Whipple surgery. Surgery is adequate as per the HPR report.

The standard recommendation for periampullary carcinoma is to treat them as pancreatic cancer so every periampullary carcinoma patient will receive chemotherapy for six months.

  1. I would consider Gemcitabine Capecitabine-based chemotherapy as an adjuvant based on the CONKO trial.
  2. Total duration is six months (six cycles).
  3. At the end of treatment, I would consider CT (computed tomography) scan or PET (positron emission tomography) and CA19.9 to document no residual disease. The patient will have to follow up every three months clinically for the next two years.

Before starting chemotherapy, I would like to assess the patient's fitness as she has undergone major surgery.

If you have any other questions you can always revert back here.

Thank you.

Patient's Query

Hi doctor,

The patient had Whipple surgery around one and a half years back.

After that, the patient had three chemotherapy cycles. The patient missed one cycle of chemotherapy due to her bad health.

Meanwhile, the patient developed jaundice.

A CT of the whole abdomen was done one month back.

I am attaching her latest prescription, blood report, and CT report of the whole abdomen.

What can be the cause of this jaundice?

Please advise.

Hello,

Welcome back to icliniq.com.

I have gone through previous case history as well as recent reports provided by you (attachments removed to protect the patient's identity).

The patient had stage-2 (pT3N0) pancreatic adenocarcinoma for which the patient had undergone Whipple surgery followed by three cycles of adjuvant GemCap.

Now, the patient had developed jaundice, predominately obstructive type. Most probably reasons for this can be, post-surgical biliary stricture or operative site recurrence. Both of them are difficult to detect on a CT scan. As seen in the recent scan provided, there is no evidence of any specific abnormality.

I would consider doing the following:

  1. PET-CT to pick the possible recurrence.
  2. Biliary drainage in form of stenting or PTBD to relieve jaundice.
  3. Endoscopy to check for any possible local recurrence or stricture development.

I would be happy to help you further if you have any other questions.

Thank you.

Patient's Query

Hi doctor,

The patient went for the follow-up to the surgeon who had performed the Whipple surgery. After examining the patient, the doctor said that he did not find any blockage.

Yesterday, all blood tests were repeated and it was found that bilirubin and the liver enzymes levels came down to normal.

The doctor had suspected that the patient's liver would not sustain chemotherapy so he had given various medicines to correct liver function only.

I am attaching the latest blood reports to understand the condition in a better way.

Hello,

Welcome back to icliniq.com.

Yesterday’s report (attachments removed to protect the patient's identity) have changed the picture completely.

Yes, bilirubin and liver enzymes are coming down to normal which is a good thing as it rules out stricture or recurrence.

Then the next probable cause is either infections or drugs. Hepatitis B and Hepatitis C reports are negative.

Yes, chemotherapy drugs can cause liver dysfunction especially in people who have UGT1A1 polymorphisms. And in that case, further chemotherapy is not advisable. I would still consider doing PET-CT to document the end of treatment, disease status and, CA19.9 levels after bilirubin levels have normalized.

The patient should be under 3 months of routine follow-up, clinically and with blood investigations to detect recurrence early.

If you have any other questions I would be happy to help you further.

Thank you for keeping me informed regarding the case.

Patient's Query

Hi doctor,

I am attaching the fibroscan reports of the patient. Again, the doctor has repeated the bilirubin test and it is found to be 15.52 mg/dL and INR is 2.1.

I am attaching the latest blood reports too. The doctor is willing to keep her in ICU for a few days.

Do you think the patient's condition is critical?

Hello,

Welcome back to icliniq.com.

I have gone through both the reports of fibroscan and bilirubin (attachments removed to protect the patient's identity).

Rising bilirubin levels are a bit worrisome. I am not worried about the fibroscan report as in acute hepatitis it is usually high.

I would advise you to do HAV-HEV IgM levels checked just to rule out vital causes.

If the consciousness of the patient is fine, there is no fever and the patient is hemodynamically stable then the patient should come out of this event.

I would advise monitoring the situation closely. Keep me updated about the liver functions. Continue with medication to support the liver. ICU (intensive care unit) care would help in managing the patient.

Can you update me on medications also that the patient she is currently taking?

Thank you.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Pawar Satyajit Jalinder
Dr. Pawar Satyajit Jalinder

Medical oncology

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