What is the best course of treatment for a 61-year-old female patient with a pancreatic mass and metastasis, and an incidental finding of a leaking aorta?

Management of a Patient with Pancreatic Mass with Metastasis and Leaking Aorta

The leaking aorta represents a life-threatening emergency that requires urgent treatment before addressing the pancreatic cancer, as aortic rupture carries an extremely high mortality rate that increases dramatically with time.

Immediate Management of Leaking Aorta

Assessment and Diagnosis

• CT scan with non-contrast phase followed by contrast injection should be performed immediately to evaluate the extent of the aortic leak and to differentiate between contained rupture and free rupture 1
• Imaging should cover the entire aorta, iliac, and femoral arteries to provide sufficient information for planning surgical or endovascular treatment 1
• Contained rupture presents with acute chest/back pain while maintaining hemodynamic stability, whereas free rupture typically leads rapidly to internal bleeding and death 1

Treatment Options

• Urgent intervention is required as mortality may be as high as 54% at 6 hours and 76% at 24 hours after the initial event 1
• Two main treatment options exist:
  • Endovascular repair (TEVAR) - preferred for suitable candidates with a 30-day mortality rate of approximately 19% 1
  • Open surgical repair - traditional approach with a higher 30-day mortality rate of approximately 33% 1
• The decision between open surgery and endovascular repair should be carefully balanced based on patient factors, anatomical considerations, and local expertise 1

Management of Metastatic Pancreatic Cancer (After Aortic Repair)

Initial Assessment

• A multiphase CT scan of chest, abdomen, and pelvis should be performed to assess the extent of disease 1
• Careful evaluation of the patient's performance status (PS), symptom burden, and comorbidity profile is essential for treatment planning 1
• Goals of care, advance directives, patient preferences, and support systems should be discussed 1

Treatment Approach Based on Performance Status

• For patients with ECOG PS 0-1 and favorable comorbidity profile:
  • FOLFIRINOX is recommended as first-line therapy 1
  • Gemcitabine plus nab-paclitaxel is an alternative first-line option 1
• For patients with ECOG PS 2 or significant comorbidities:
  • Gemcitabine alone is recommended 1
  • Addition of capecitabine or erlotinib may be considered 1
• For patients with ECOG PS ≥3 and poorly controlled comorbidities:
  • Supportive care should be emphasized 1
  • Cancer-directed therapy should only be offered on a case-by-case basis 1

Supportive Care Measures

• Pain management:
  • Consider neurolytic celiac plexus block which provides better pain control and reduces opioid consumption 1
  • Early neurolytic sympathectomy leads to better pain control and quality of life 1
• Nutritional support:
  • Consultation with a nutritionist/dietician 1
  • Pancreatic enzyme replacement therapy for patients with exocrine insufficiency 1
• Management of biliary obstruction:
  • Endoscopic placement of self-expanding metal stents to re-establish drainage 1
  • Metal stents are generally preferred; plastic stents can be considered for patients expected to survive <3 months 1
• Venous thromboembolism prevention:
  • Pancreatic cancer has one of the highest incidences of VTE among malignancies 1
  • Consider primary prophylaxis with low-molecular-weight heparins in high-risk patients 1

Special Considerations and Pitfalls

• The timing of cancer treatment must be carefully coordinated with recovery from aortic repair to minimize complications 1
• Gemcitabine is FDA-approved for first-line treatment of metastatic pancreatic adenocarcinoma but should only be initiated after the patient has recovered from aortic repair 2
• Multidisciplinary collaboration between vascular surgery, medical oncology, and palliative care is essential for optimal management 1
• Clinical trials should be considered at all stages of treatment if the patient is eligible 1
• The prognosis for metastatic pancreatic cancer remains poor with a 5-year overall survival of approximately 2% 1