General Surgery · Year 3 · from General Surgery

Case 2: Pancreatic Adenocarcinoma

Patient Demographics

  • Age: 68 years
  • Sex: Female
  • Occupation: Retired accountant

Chief Complaint

"I've turned yellow and my urine is very dark."

History of Present Illness

The patient presents with a 3-week history of progressive jaundice, dark urine, and clay-colored stools. She reports generalized pruritus that has been keeping her awake at night. She has had vague epigastric discomfort and back pain for approximately 2 months. She has lost 7 kg over the past 2 months with decreased appetite. She denies prior episodes of jaundice, biliary colic, or pancreatitis. She has new-onset diabetes diagnosed 4 months ago.

Past Medical History

  • New-onset diabetes mellitus (4 months ago - potentially paraneoplastic)
  • Hypertension
  • No prior surgeries

Family History

  • Brother: Pancreatic cancer at age 71

Social History

  • Never smoker
  • Minimal alcohol use

Physical Examination

  • Vitals: Normal
  • General: Cachectic, jaundiced female
  • Abdomen:
  • Soft, mild epigastric tenderness
  • Palpable, non-tender gallbladder (Courvoisier's sign)
  • No hepatomegaly
  • No ascites
  • Skin: Markedly icteric, excoriations from scratching

Laboratory Results

  • Total bilirubin: 14.8 mg/dL
  • Direct bilirubin: 12.4 mg/dL
  • ALT: 186 U/L
  • AST: 142 U/L
  • Alkaline phosphatase: 486 U/L
  • GGT: 620 U/L
  • CA 19-9: 584 U/mL (markedly elevated)
  • CEA: 4.2 ng/mL (mildly elevated)
  • Albumin: 3.2 g/dL
  • Hemoglobin: 11.2 g/dL
  • Glucose: 186 mg/dL

Imaging

CT Abdomen/Pelvis (pancreatic protocol):

  • 3.2 cm hypodense mass in pancreatic head
  • Dilated intrahepatic and extrahepatic bile ducts (CBD 15 mm)
  • Dilated pancreatic duct (double duct sign)
  • Distended gallbladder
  • Superior mesenteric vein abutment (<180 degrees) - borderline resectable
  • No superior mesenteric artery involvement
  • No liver metastases
  • No ascites or peritoneal nodules

MRI/MRCP:

  • Confirms pancreatic head mass
  • Abrupt cutoff of CBD and main pancreatic duct
  • No liver lesions

EUS with FNA:

  • 3.2 cm hypoechoic mass in pancreatic head
  • FNA: Positive for adenocarcinoma
  • No celiac axis involvement

Staging

  • Borderline resectable pancreatic adenocarcinoma
  • cT3N0M0 (Stage IIA) - pending final pathology

Multidisciplinary Tumor Board

  • Borderline resectable due to SMV abutment
  • Recommendation: Neoadjuvant therapy followed by surgery

Preoperative Biliary Decompression

  • ERCP with plastic stent placement
  • Bilirubin decreased to 3.2 mg/dL over 2 weeks
  • Improved nutritional status and operative candidacy

Neoadjuvant Therapy

  • FOLFIRINOX x 4 cycles
  • Restaging CT: Tumor stable, SMV abutment unchanged
  • CA 19-9 decreased to 86 U/mL

Operative Procedure

Pancreaticoduodenectomy (Whipple procedure):

  • Exploratory laparotomy - no metastases
  • Standard Whipple with portal vein resection (tangential) and primary repair
  • Reconstruction:
  • Pancreaticojejunostomy (duct-to-mucosa)
  • Hepaticojejunostomy
  • Gastrojejunostomy

Pathology Results

  • Pancreatic ductal adenocarcinoma, 2.8 cm (treatment effect present)
  • Moderately differentiated
  • Margins: R0 (negative)
  • Lymph nodes: 1/22 positive
  • Portal vein involved (negative margin after resection)
  • ypT3N1M0 (Stage IIB)

Postoperative Course

  • ICU x 2 days
  • Delayed gastric emptying (common complication)
  • Started on enteral feeds via J-tube
  • Eventually tolerating oral diet
  • Discharged POD 14

Adjuvant Therapy

  • Complete 6 months of perioperative therapy with FOLFIRINOX

Surveillance

  • CA 19-9 every 3 months
  • CT every 3-6 months for 2 years

Teaching Points

  1. Painless jaundice + palpable gallbladder = Courvoisier's sign (suggests malignant obstruction)
  2. New-onset diabetes can be presenting sign of pancreatic cancer
  3. CA 19-9 useful for monitoring (not screening)
  4. Resectability determined by vascular involvement
  5. Neoadjuvant therapy for borderline resectable disease
  6. Whipple procedure is standard for pancreatic head cancer
  7. Median survival improved with multimodal therapy

Clinical Image

Image Description: CT scan demonstrating a hypodense mass in the pancreatic head with associated dilation of the common bile duct and pancreatic duct (double duct sign). The mass causes biliary obstruction leading to painless jaundice.

Attribution: Image from Wikimedia Commons, Category:Pancreatic cancer. Source: https://commons.wikimedia.org/wiki/Category:Pancreatic_cancer

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