A 61-year-old male with a history of hypertension, well-controlled on metoprolol, presents with complaint of left upper quadrant abdominal pain, bloating and dyspepsia after meals for four months. He admits to loss of appetite and early satiety without weight loss, nausea or vomiting. He denies a history of NSAID use. On physical examination, he has mild tenderness to deep palpation in the epigastrium and left upper quadrant without rebound tenderness or guarding. No palpable hepatosplenomegaly. Abdominal ultrasound was unremarkable, with limited examination of the pancreas due to bowel gas.

Labs: total bilirubin 0.9mg/dL, AT 20 U/L, ALT 22 U/L, ALP 59 U/L, lipase 79 U/L, amylase 38 U/L.

His symptoms were unresponsive to a two-week proton pump inhibitor trial (omeprazole). Due to persistent symptoms, a CT scan was ordered. This showed a 3.5-cm x 3.2-cm pancreatic head mass (Figure 1) with multiple enlarged peripancreatic pericaval lymph nodes and new bile duct dilatation.

Figure 1: CT scan showing a pancreatic head mass.

Photo courtesy of Sarah Enslin, PA-C.

What is the next appropriate step for evaluation?

A) MRCP of the abdomen
B) Endoscopic ultrasound
C) Gastric emptying study
D) Percutaneous pancreatic biopsy

The correct answer is B, endoscopic ultrasound (EUS). The primary concern is pancreatic malignancy. An EUS with fine needle aspiration/fine needle biopsy is the appropriate next step in evaluation.

Practice Pearls

General

• Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death in the United States.¹
• Modifiable risk factors include tobacco use, obesity, diabetes and chronic pancreatitis.²
• Nonmodifiable risk factors include age older than 65 years, race, family history and inherited genetic syndromes (mutations in BRCA1, BRCA2, PALB2, PRSS1 genes; familial atypical multiple mole melanoma, hereditary nonpolyposis colon cancer, Peutz-Jeghers syndromes).²
• PDAC is often diagnosed at a late stage (<20 percent of patients have surgically resectable disease at time of diagnosis).²
• PDAC is most commonly found in the head of the pancreas (~70 percent).²
• The five-year prognosis is poor, even with surgical resection (30 percent if complete R0 resection; 10 percent if node-positive disease).²
  

Diagnosis

• Initial testing for patients with suspected pancreatic cancer includes blood work (liver function tests) and abdominal imaging.²
• Ultrasound is often performed due to its high sensitivity for detecting biliary tract dilation and its availability and safety; however, a CT scan is often needed to evaluate the pancreas, which is at least partially obscured on ultrasound due to overlying bowel gas.²
• The most common presenting symptoms are upper abdominal pain, jaundice and weight loss.²
• A recent diagnosis (<2 years) of diabetes may be noted.²
• Carbohydrate antigen 19-9 can assist in the diagnosis of pancreatic cancer, but elevated levels are not diagnostic on their own.²
• An EUS-guided pancreatic mass biopsy is the test of choice for histologic confirmation.²
  

Treatment

• Multidisciplinary consultation (gastroenterology, surgery, oncology, pathology, radiology) at a high-volume center is recommended for treatment discussions.³
• Staging scans with chest and pelvic CT scans should be completed.³
• MRI may be helpful for evaluation of indeterminate liver lesions.³
• Consider PET scan in patients at high risk for metastatic disease.³
• For patients with resectable disease, surgery is recommended (with or without neoadjuvant therapy.)³
• First-line therapy for patients with borderline resectable disease includes chemotherapy with or without radiation.³
• Patients with evidence of biliary obstruction should undergo ERCP for biliary decompression.³

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• References