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Stem A (resectable head mass)
A 68-year-old man presents with progressive painless jaundice, dark urine, pale stools, pruritus, and 8 kg weight loss. Examination: deep jaundice; palpable non-tender gallbladder. CT pancreas protocol: 3 cm head mass, clear SMA/SMV/coeliac planes, no metastases. CA 19-9 420 U/mL. ECOG 0. INR 1.4.
Stem B (unresectable — for part d)
Separately, CT shows encasement of the SMA >180° with liver metastases. He has severe epigastric/back pain and steatorrhoea.
Questions
a) Name the sign/law and explain its pathological rationale. Differential for painless progressive jaundice. (3 marks)
Courvoisier’s sign/law: in a jaundiced patient a palpable gallbladder is unlikely due to stones (chronic cholecystitis → fibrotic contracted GB); suggests distal malignant biliary obstruction (pancreatic head, periampullary, distal cholangiocarcinoma).
Differential: pancreatic head PDAC, ampullary carcinoma (often earlier jaundice, better prognosis), distal cholangiocarcinoma, chronic pancreatitis mass, autoimmune pancreatitis (IgG4), choledocholithiasis (usually painful ± cholangitis, non-palpable GB).
b) Preoperative optimisation and standard resection with three anastomoses. (4 marks)
Optimise: vitamin K (phytomenadione) 10 mg IV daily × 1–3 days for coagulopathy; correct electrolytes; nutrition; treat cholangitis if present. Routine preoperative biliary drainage not required in all resectable jaundiced patients — indicated for cholangitis, neoadjuvant delay, or severe symptomatic jaundice per centre protocol.
Whipple pancreatoduodenectomy: resect head of pancreas, duodenum, gallbladder, distal CBD ± distal stomach (pylorus-preserving variant).
Reconstruction: (1) pancreaticojejunostomy, (2) hepaticojejunostomy, (3) gastrojejunostomy (or duodenojejunostomy). High-volume centre. Most feared complication: post-op pancreatic fistula → pseudoaneurysm → sentinel bleed.
c) Adjuvant therapy after R0 resection and prognosis figures examiners expect. (3 marks)
Adjuvant mFOLFIRINOX × 12 cycles if fit (PRODIGE 24: median OS ~54 vs ~35 months vs gemcitabine). Less fit: gemcitabine ± capecitabine.
Overall 5-year survival <10%; after R0 resection roughly 20–25% (higher with modern multi-agent adjuvant). Only ~15–20% resectable at presentation. KRAS mutated in >90% PDAC.
d) Stem B — palliative package with procedures and systemic options. (5 marks)
- ERCP SEMS (covered metal) for biliary obstruction; duodenal SEMS or gastrojejunostomy if GOO
- Analgesia: WHO ladder; coeliac plexus block for refractory visceral pain
- PERT (pancreatic enzyme replacement) with meals for steatorrhoea; fat-soluble vitamins
- Systemic: fit → FOLFIRINOX; less fit → gemcitabine + nab-paclitaxel; BRCA/HRD may use platinum ± PARP later
- Early palliative care; VTE risk high (Trousseau) — low threshold to treat thrombosis
- Tissue diagnosis (EUS-FNA) before non-surgical systemic therapy
Additional teaching points
New-onset diabetes in thin older adult + weight loss → consider PDAC imaging.
Borderline resectable (limited venous contact) → MDT, often neoadjuvant.
Body/tail presents later with pain/weight loss, often unresectable; distal pancreatectomy ± splenectomy if localised.