Painless Obstructive Jaundice?
The patient is a 57-year-old male with an ultrasound of gallbladder for stones, a computerized tomography (CT) scan of the abdomen for stones and a pancreatic mass, and abnormal HIDA scan that showed no uptake into the gallbladder or biliary tree. The patient has obstructive jaundice with a serum total bilirubin of 4.5 mg/dL and an alkaline phosphatase of 500 mcmol/L. He presented to the emergency department 3 days ago; his endoscopic retrograde cholangiopancreatogram (ERCP) today shows a stricture in the distal common bile duct without stones. A biliary stent was placed. He has had no prior surgery. Can you recommend the next step?
Painless obstructive jaundice is a hallmark of pancreatic cancer, yet several clinical and diagnostic features must be kept in mind. First and foremost is the clinical presentation. Although painless jaundice is a typical presentation of pancreatic cancer, other symptoms such as pruritus, weight loss, and back pain may accompany jaundice. Also, patients with long-standing alcohol abuse may develop chronic pancreatitis with a biliary stricture. This patient has had an extensive work-up and no further diagnostic tests are necessary before recommending surgery for a pancreatic mass, but other potential diagnostic tests include magnetic resonance imaging (MRI), especially magnetic resonance cholangiopancreatography, endoscopic ultrasound (EUS) with fine-needle aspiration (FNA), or ERCP with brushings. MRI provides little information over a high-quality CT and brushings are diagnostic in only 50% of cases. EUS may be helpful, especially if histologic confirmation of cancer is desired. However, even if the FNA via EUS and brushings are negative, a pancreatic cancer must still be presumed. High-quality imaging will also help with the staging of a pancreatic cancer. For instance, if the cancer involves the superior mesenteric artery or vein, the cancer is usually unresectable and treatment options other than surgery should be considered. In summary, this patient has had an adequate diagnostic work-up and should be seen by a pancreatic surgeon. Several reports suggest that outcomes with pancreatic resection are safer when the surgery is performed in a high-volume pancreatic center; therefore, this patient should be evaluated by an experienced pancreatic surgeon.
Surgery remains the mainstay treatment of pancreatic cancer. The mortality of a pancreatoduodenectomy is 1% to 3% in high-volume centers and morbidity is approximately 30%. The outcome of surgery may be greatly influenced by the patient's comorbidities and nutritional status. Several centers have adopted diagnostic laparoscopy prior to open operation to detect occult metastases. These studies suggest that approximately 30% of patients can be spared an open exploration by detecting small metastatic deposits or vascular invasion. Five-year survival with surgery has approached 20% and quality of life has been reported as good following resection. Most centers, however, would recommend multimodality therapy consisting of surgery followed by radiation therapy and chemotherapy, depending upon the stage of the tumor. Multiple chemotherapeutic regimens are under trial, but thus far no regimen has clearly surpassed 5-FU with radiation therapy. However, because of the poor overall survival, patients and referring physicians are encouraged to seek consultation from oncologists who can offer treatment in one of the many ongoing trials.
The patient is a 57-year-old male with an ultrasound of gallbladder for stones, a computerized tomography (CT) scan of the abdomen for stones and a pancreatic mass, and abnormal HIDA scan that showed no uptake into the gallbladder or biliary tree. The patient has obstructive jaundice with a serum total bilirubin of 4.5 mg/dL and an alkaline phosphatase of 500 mcmol/L. He presented to the emergency department 3 days ago; his endoscopic retrograde cholangiopancreatogram (ERCP) today shows a stricture in the distal common bile duct without stones. A biliary stent was placed. He has had no prior surgery. Can you recommend the next step?
Painless obstructive jaundice is a hallmark of pancreatic cancer, yet several clinical and diagnostic features must be kept in mind. First and foremost is the clinical presentation. Although painless jaundice is a typical presentation of pancreatic cancer, other symptoms such as pruritus, weight loss, and back pain may accompany jaundice. Also, patients with long-standing alcohol abuse may develop chronic pancreatitis with a biliary stricture. This patient has had an extensive work-up and no further diagnostic tests are necessary before recommending surgery for a pancreatic mass, but other potential diagnostic tests include magnetic resonance imaging (MRI), especially magnetic resonance cholangiopancreatography, endoscopic ultrasound (EUS) with fine-needle aspiration (FNA), or ERCP with brushings. MRI provides little information over a high-quality CT and brushings are diagnostic in only 50% of cases. EUS may be helpful, especially if histologic confirmation of cancer is desired. However, even if the FNA via EUS and brushings are negative, a pancreatic cancer must still be presumed. High-quality imaging will also help with the staging of a pancreatic cancer. For instance, if the cancer involves the superior mesenteric artery or vein, the cancer is usually unresectable and treatment options other than surgery should be considered. In summary, this patient has had an adequate diagnostic work-up and should be seen by a pancreatic surgeon. Several reports suggest that outcomes with pancreatic resection are safer when the surgery is performed in a high-volume pancreatic center; therefore, this patient should be evaluated by an experienced pancreatic surgeon.
Surgery remains the mainstay treatment of pancreatic cancer. The mortality of a pancreatoduodenectomy is 1% to 3% in high-volume centers and morbidity is approximately 30%. The outcome of surgery may be greatly influenced by the patient's comorbidities and nutritional status. Several centers have adopted diagnostic laparoscopy prior to open operation to detect occult metastases. These studies suggest that approximately 30% of patients can be spared an open exploration by detecting small metastatic deposits or vascular invasion. Five-year survival with surgery has approached 20% and quality of life has been reported as good following resection. Most centers, however, would recommend multimodality therapy consisting of surgery followed by radiation therapy and chemotherapy, depending upon the stage of the tumor. Multiple chemotherapeutic regimens are under trial, but thus far no regimen has clearly surpassed 5-FU with radiation therapy. However, because of the poor overall survival, patients and referring physicians are encouraged to seek consultation from oncologists who can offer treatment in one of the many ongoing trials.