Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 64-year-old man is evaluated for a 3-month history of abdominal bloating and mid-epigastric discomfort associated with a 6.8-kg (15-lb) weight loss. The patient has no significant medical history and takes no medications.
On physical examination, vital signs are normal, and the only significant finding is mild epigastric tenderness.
|Complete blood count||Normal|
|Aspartate aminotransferase||55 U/L|
|Alanine aminotransferase||67 U/L|
(A mobile quick reference of normal lab values is available for download online.)
Helical CT scan of the abdomen shows a 2.8-cm pancreatic body mass. There are no liver lesions and no invasion into surrounding major vessels. Endoscopic ultrasonography confirms the presence of an approximately 3-cm lesion without vascular invasion. A fine-needle aspiration specimen is positive for adenocarcinoma.
Which of the following is the most appropriate next step in the management of this patient?
A) Combined radiation therapy and chemotherapy
B) Distal pancreatectomy
C) Palliative care consultation
D) Pancreatic enzyme supplementation
MKSAP Answer and Critique
The correct answer is B) Distal pancreatectomy. This item is available to MKSAP 15 subscribers as item 34 in the Gastroenterology and Hepatology section.
At the time of diagnosis, about 80% to 85% of pancreatic cancers are unresectable because of distant metastases or invasion or encasement of the major blood vessels. Treatment of pancreatic cancer that has not metastasized nor spread to the local vasculature is surgical resection, with distal pancreatectomy being the preferred procedure for lesions of the pancreatic body. Evaluation of whether the tumor is resectable preoperatively is performed with a combination of helical CT of the abdomen and endoscopic ultrasonography. Even with surgery and complete resection of the tumor, the 5-year survival rate is only 10% to 30%.
Concurrent radiation therapy and chemotherapy alone delay disease progression and may improve survival in patients with localized unresectable pancreatic cancer but will not provide a cure in patients with localized resectable pancreatic cancer. Pancreatic enzymes are used in patients with chronic pancreatitis or after pancreatic surgery to treat pancreatic malabsorption. In this otherwise healthy patient with a localized lesion and a potential for curative resection, palliative care is not indicated.
- Surgery is the only treatment that provides a potential cure in patients with localized pancreatic cancer, with a 5-year survival rate of 10% to 30%.
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