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Case History

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Image not available. A 74-year-old man presents with weight loss, jaundice, dark urine and pale stools. A computed tomography (CT) scan confirms mass in the head of the pancreas with no evidence of metastatic disease. The patient undergoes a pylorus-preserving pancreaticoduodenectomy. Histological examination confirms adenocarcinoma. A year later he presents with abdominal pain and weight loss. A CT scan confirms liver metastases.

What are the initial investigations and immediate management?

If the patient is fit for a major pancreatic resection what factors determine resectability?

What are the important prognostic factors? What advice would you give regarding adjuvant treatment?

What treatment options are available in patients with locally advanced disease?

What advice would you give the patient on presentation of metastatic disease?

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Background

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What are the initial investigations and immediate management?

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Image not available. Initial investigations are aimed at obtaining a definitive diagnosis. An ultrasound scan of the liver can detect bile duct dilatation and a mass in the head of the pancreas. CT has better sensitivity than ultrasound and can detect extrapancreatic spread such as liver metastases, lymphadenopathy and ascites. Endoscopic retrograde cholangiopancreatography (ERCP) has high sensitivity and specificity and is of particular use if CT or ultrasound does not reveal a mass. ERCP is useful in patients requiring relief of biliary obstruction. Percutaneous transhepatic cholangiography (PTCA) is an alternative to ERCP for relief of biliary obstruction and is recommended if ERCP fails or cannot be done. Magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice where ERCP/PTCA is not possible as a three-dimensional image can be created of the pancreatic and biliary tree, liver and adjacent vascular structures.

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The most important immediate management is relief of biliary obstruction, usually achievable by an endoscopically placed stent. It is considered as effective as a surgical bypass, with lower morbidity and procedure-related mortality.1 The disadvantages are more frequent readmissions for stent occlusion, recurrent jaundice and cholangitis. Patients with resectable disease should ideally have surgery before relief of biliary obstruction, but in practice this is seldom practical or possible.

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In unresectable disease, try to obtain a tissue diagnosis. This can be achieved by percutaneous ultrasound or CT-guided fine-needle aspiration (FNA) or biopsy, endoscopic ultrasound-assisted FNA or biopsy or brushings at ERCP. Once a tissue biopsy is obtained, the patient should be referred to an oncologist for further management.

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Discussion

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If the patient is fit for a major pancreatic resection what factors determine resectability?

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Image not available. The factors determining resectability are:

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  • patient's fitness and willingness to undergo a major pancreatic resection

  • lack of major vessel involvement including the portal vein, superior mesenteric artery and vein, coeliac axis and hepatic artery

  • absence of metastatic disease.

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Three-phase CT scanning provides useful information about major vessel involvement which is essential in determining resectability. Endoscopic ultrasound is also increasingly used in the ...

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