Pancreatic cancer

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Step 1: View clinicals

A 59-year-old man presents with intermittent epigastric pain and mild jaundice for one month. His urine has become darker over the same time. He has also lost five kilograms of weight over the last three months. His medical and surgical histories are unremarkable. He is not on any medications, including over-the-counter drugs or herbal supplements. There is no family history of malignancies. He is a heavy smoker, with a total pack-history of 40 years. He has also consumed three to four units of alcohol a day for almost a decade. A complete blood count and renal profile are within normal parameters. However, a liver profile shows ALP 467 U/L (normal: 45-115), GGT 321 U/L (normal: 9-48), total bilirubin 2.3 mg/dL (normal: 0.1-1.3), and direct bilirubin 2.1 mg/dL. Liver transaminases, serum albumin levels and the INR are all normal. Serum amylase and lipase are also within normal levels.


Step 2: Order all relevant investigations

Ultrasound abdomen

The pancreatic duct is dilated, with a maximum diameter of 5 mm. The common bile duct is not dilated, showing a maximum diameter of 4 mm. The remainder of the biliary tree is normal, with no areas of focal thickening or cystic dilatation. The gallbladder is normal. No gallstones are seen. The porta hepatis is normal. There are no focal hepatic lesions. The head of the pancreas cannot be visualized. No intra-abdominal masses are noted.

Contrast CT abdomen

Contrast helical computed tomography (CT) of the abdomen shows a 4.5 cm x 3.5 cm mass within the head of the pancreas and invading the intrapancreatic portion of the bile duct. There is no evidence of extrapancreatic disease or extension to the superior mesenteric artery or celiac axis. The superior mesenteric-portal confluence appears patent. No enlarged lymph nodes are seen. Follow-up triphasic CT demonstrates enhancement of the mass in the arterial phase.

Endoscopic ultrasound + fine-needle aspiration

Endoscopic ultrasound shows a hypoechoic 3.5 cm x 3.0 cm mass within the pancreatic head. Multiple fine-needle aspiration specimens are obtained. These confirm the presence of pancreatic adenocarcinoma.

CA 19-9 levels

CA 19-9: 35 U/mL(0-37)


Step 3: Select appropriate management

Corticosteroids
Pancrelipase
Endoscopic stenting
Oncology referral


Score: ★★☆