1. DR. WILLIAM OLALIA MATIAS  MAULION  MEDENILLA  MEDINA

2. HISTORY  Two months PTC  Vague abdominal pain and anorexia  One month PTC  Progressive yellowish discoloration of the sclera  Tea-colored urine  Pruritus  Acholic stools  20% Weight loss

3. PAST PERSONAL HISTORY  Heavy smoker (3 pack years)  Occasional beverage drinker  No history of hepatitis  Known hypertensive (10 years)  Captopril  Metoprolol  No history of DM

4. PE FINDINGS  Vital Signs: Normal  Icteric sclerae  (-) Palpable cervical or supraclavicular LN  Heart & Lungs: Normal  Abdomen  Globular with vague ballotable mass at RUQ  Smooth, non tender and moves with respiration  (-) Fluid wave  Rectal Exam: Acholic stools

6. Lab FindingsNormal Value CBCNormal Creatinine2 mg/dL0.6 – 1.5mg/dL Alk. Phosphatase500 u/L32 – 110 u/L Total Protein6.5 g/dL5 – 9 g/dL Albumin3.5 g/dL3.5 – 5.0 g/dL Globulin2.5g/dL CA 19-9350 units/mL< 37 units/mL DIAGNOSTIC WORK-UP

7.  Chest X-ray: Normal  Ultrasound  Distended gallbladder with no stones  CBD 2.5 cm  Dilated intrahepatic ducts  Enlarged head of the pancreas  Normal Liver

8. ANCILLARY DIAGNOSTIC TOOLS  ERCP  CT Scan  MRI  EUS

9.  Homogenous echotexture  No hyperechoic structures were noted  Presence of dilated intrahepatic ducts

10.  (L) Dilated gallbladder. No stones or calcifications/posterior shadowing present.  (R) Dilated CBD

11.  Hyperechoic masses: Presence of extrahepatic mass

18. SALIENT FEATURES  Progressive jaundice  Tea-colored urine  Acholic stools  Pruritus  Vague abdominal pain  Anorexia  Weight loss  Icteric sclerae  Abdomen  Globular with vague ballotable mass at RUQ  Smooth, non tender and moves with respiration  Rectal Exam: Acholic stools

19.  Biliary Tract Obstruction secondary to Pancreatic Head Malignancy

20.  Head 80%, body 15%, tail 5% Types  Ductal adenocarcinoma, most common  Intraductal papillary mucinous carcinoma  Mucinous cystadenocarcinoma Age  Peak age incidence: 65-75 years old  40-45% locally advanced  40-45% metastatic  10-20% localized resectable

21. CLINICAL PRESENTATION  Jaundice (progressive), pruritus  Anorexia, weight loss  Back pain  an indication of advance disease because retroperitoneal nerves may have already been affected  Palpable GB (Courvoisier’s sign)  Virchow’s node (left supraclavicular node), Sister Joseph’s sign (nodules in the umbilicus)  denote advanced malignancy

22. RISK FACTORS  Tobacco smokingFamilial background  Peutz-Jeghers syndromeHNPCC  Li-Fraumeni syndromeFAP  Chronic pancreatitis PROGNOSIS  Advanced disease: overall median survival <6 months; 5-year survival rate 0.4-5%  2.6-9% undergo pancreatic resection  OMS 11-20 months  5-year survival rate 7-25%: relatively fatal since it presents usually at an advance stage  All patients die within 7 years of diagnosis

24. No Yes Clinical, US, CT, ERCP, EUC, MRCP Multidisciplinary team Surgeon Nursing staff Anesthetists Radiology Intensivist Gastroenterology Dieticians Pathology Oncology Biopsy Palliative care Stenting Surgical bypass Pain relief Chemotx Radiotc New Rx Dx of pancreatic cancer Is patient fit for resection? Resection Kausch-Whipple KW-PP Left resection Assess respectability CECT, EUS Adjuvant treatment Enzyme supplements Chemotherapy Novel treatments

25. Resectable? YesNo Good risk Poor risk Whipple’s PPPD Endoscopic drainage Bypass Cholecystojejunostomy with Gastrojejunostomy Hepaticojejunostomy with Gastrojejunostomy ERCP

26. Staging of Pancreatic Cancer Primary Tumor (T) T1Limited to pancreas, < 2 cm T2Limited to pancreas, > 2 cm T3Extension into duodenum or bile duct T4Extension into portal vein, SMV, SMA, Stomach, Spleen, Colon Regional Lymph Nodes (N) N0No nodal metastases N1Regional nodal metastases Distant Metastases (M) M0No distant metastases M1Distant metastases (Liver, Lung)

27. StageTNMDescription I1,200Tumor confined to pancreas II300Tumor invades duodenum &/or bile duct, no nodal involvement III1,2,310Tumor has not spread beyond duodenum or bile duct but includes regional lymph nodes IVA4Any0Locally advanced tumor growing into blood vessels, stomach, spleen, and colon with or without lymph node involvement IVBAny 1Distant metastases (liver, lungs) present