Higher CA 19.9 Levels in Post operative condition

[govindraj]

Patient : Hemalatha Pai , Mumbai , India Female 56 Years
Problem : Scantly differentiated Adenocarcinoma in very first stage    Pre-operation : CA 19.9 at 456 U/ml
Operation Done on : 26th July 2007                
Surgery result : Successfull removal with clear nodes CA 19.9 at 256 U/ml.
Currently CA 19.9 levels are rising with 3 month pattern in values 400 , 660 , 950 and 3500 U/ml.
Pet Scan show some liquid formation in left Lymp node of neck. However FNCA test (Biopsy) show no malignancy in smears of sample drawn with help of sonography.
Doctors recommend further to take Chemotherapy.
Patient else is extremely healthy with no problems in diet or neck and carries out duties on normal person.

Kindly suggest reasons for rise in CA 19.9 levels and any other treatement for Cure possible.      

  

[Fernando Roque, MD]

Hi.  You did not mention it, so I'm assuming that the adenocarcinoma was found in the pancreas. Is this correct?  If it is, the rising CA 19-9 levels could very well indicate disease progression or recurrence.  You mentioned that a PET scan was done.  Was the pancreas included in that scan? If so, what were the results pertaining to the pancreas?  If there is evidence of cancer recurrence around the pancreas by PET imaging, then chemotherapy is indeed warranted.  The fine needle aspiration biopsy of that lymph node is not adequate for the purpose of detecting possible recurrence.  It would have been better if an excision biopsy of the node were done, because this lessens the chance for a false negative result.

[govindraj]

Thank you sir , for your immediate reply. I am answering your questions point wise:-
1) The Carcinoma was of pancreas.
2) Full body PET SCAN was done. The report reads as follows:-

Findings: There is a Focal increased FDG concentration seen in the enlarged, 2 cms left level II (max SUV 5.5) and 1.73 cm sized left supraclavicular (max SUV 2.3) node.

              There is a focal tracer uptake seen in the enlarged right axillary (MAX SUV 3) and the reactive right axillary node (max SUV 2.2)

              Diffuse minimal tracer uptake seen in the post operative region. (max SUV 2.5)

              Rest of the body scan is unremarkable and represents Physiological uptake.

SCAN FINDINGS REVEAL : MINIMUM HYPERMETABOLISM SEEN IN THE ENLARGED LEFT SUPRACLAVICULAR NODE. NO OTHER SITE OF FDG CONCENTRATION ELSEWHERE IN THE BODY.

FINAL REPORT : ABSENT BASELINE STUDY HENCE THE FDG UPTAKE CHARACTERISTICS OF THIS DISEASE IS UNKNOWN IN THIS PATIENT. IN THE PRESENT CLINICAL CONTEXT THE MINIMUM HYPERMETABOLISM IS THE LEFT SUPRACLAVICULAR NODE APPEARS DUE TO INVOLVEMENT OF MALIGNANT DISEASE PROCESS.


3) On visit to doctor on 11/04/2008 , they said if there is agressive recurrence it shall be only final stage. Currently as she physically fine, there is no Chemo method available wit them to cure it.

Also on other hand we also know a patient whos having similiar problem with operation done 2 years back. His CA 19.9 levels keep varying between 900 to 250 levels. But the patient is all find. Can we expect the same in our patients case.

Or there would be a definate life age for our patient ? Please reply.

Kindly suggest if any method is available to do so.

[Fernando Roque, MD]

Hi.  The progressively increasing levels of CA 19-9 are highly suggestive of pancreatic cancer recurrence, but this test alone does not conclusively prove cancer recurrence.  That was why the PET scan was done to visualize where the recurrence is located.  The problem with Ms. Pai's case is that the left supraclavicular node pinpointed by PET as the possible location of recurrent cancer, did not yield any malignant cells on fine needle aspiration cytology (FNAC).  The question is: should we believe the FNAC results? Or is the negative result due to inadequate sampling of the node?  I have said in my earlier post that an excision biopsy of the node should be done instead of the FNAC, to resolve any doubts about the veracity of the negative finding.  

Another possibility which may account for the high levels of CA 19-9 and a negative FNAC result is that there is indeed recurrent cancer, but it is located elsewhere and is  NOT in the supraclavicular node .  It is possible that the PET scan was not able to detect a recurrent cancerous mass if that mass does not have increased uptake of fluorodeoxyglucose (FDG) at the time the PET was done.  My suggestion is to do a repeat CT of the abdomen, particularly of the pancreatic area, to see if there are any masses or enlarged lymph nodes which were not visualized by PET.

We cannot assume that just because the patient looks and feels fine at the moment, the CA 19-9 elevation is spurious and cancer recurrence is unlikely.  Every means should be exhausted to rule out the possibility of recurrence.

If this were indeed recurrent pancreatic cancer, her doctors are correct in saying that there is no chemotherapy regimen available which will cure the disease at this stage.  But regimens which include the drug gemcitabine can help prolong her survival. A study by Burris, et al (1997) comparing gemcitabine with the previous standard of treatment- 5-FU, showed that those treated with gemcitabine had an 18% 1-year survival rate compared to only a 2% 1-year survival rate for those treated with 5-FU.