Oral Board Case: Pancreatic Cancer

What is your differential diagnosis and initial workup for this patient with obstructive jaundice?

Expected answer

Differential includes periampullary malignancy (pancreatic head ductal adenocarcinoma, ampullary, distal cholangiocarcinoma, duodenal carcinoma), as well as benign causes such as choledocholithiasis, benign stricture, and chronic pancreatitis. PDAC is the most common periampullary cancer (~66%). I would obtain CBC, CMP, LFTs (expect a conjugated hyperbilirubinemia and elevated alkaline phosphatase), coagulation studies, and tumor markers CA 19-9 and CEA. The key imaging study is a pancreas-protocol CT: multidetector spiral CT with IV contrast in arterial and portal venous phases to define the mass and its relationship to vasculature.

Why is a pancreas-protocol CT preferred over a standard abdominal CT, and what are you specifically looking for?

Expected answer

A pancreas-protocol CT uses thin-slice multidetector technique with arterial and portal venous phases, which optimizes visualization of the pancreatic parenchyma, the tumor, and its relationship to critical vasculature. I am assessing involvement of the SMA, celiac axis, common hepatic artery, SMV, and portal vein; the degree of vessel contact (≤180° vs >180°), the presence of contour deformity or thrombosis, regional lymphadenopathy, and distant metastases (liver, peritoneum). These findings determine whether the tumor is resectable, borderline resectable, or locally advanced/metastatic.

How do you define resectable, borderline resectable, locally advanced, and metastatic disease?

Expected answer

Resectable: no arterial contact and ≤180° venous (SMV/PV) contact without contour irregularity. Borderline resectable: arterial contact ≤180° of SMA/celiac, or hepatic artery contact amenable to reconstruction, or venous contact >180°/short-segment occlusion that is reconstructable. Locally advanced/unresectable: arterial encasement >180° of SMA or celiac, or unreconstructable venous involvement. Metastatic: distant spread (liver, peritoneum, distant nodes). Borderline and locally advanced disease are treated with neoadjuvant therapy and reassessed for resectability.

The mass appears resectable on imaging. Do you need a tissue diagnosis before taking him to the OR?

Expected answer

For a clearly resectable periampullary mass in a fit patient where I plan to proceed directly to pancreaticoduodenectomy, tissue diagnosis is not mandatory—a negative biopsy does not exclude cancer and would not change the operative plan. Tissue diagnosis via EUS/ERCP is required when neoadjuvant therapy is planned (borderline/locally advanced/metastatic) or when the diagnosis is genuinely in doubt. For this resectable patient I can proceed to resection after staging.

He is markedly jaundiced. Do you stent the biliary tree before surgery?

Expected answer

Routine preoperative biliary stenting is NOT recommended for resectable patients proceeding promptly to surgery, as it increases perioperative infectious complications without improving outcomes. Preoperative biliary decompression is indicated for cholangitis, severe symptomatic pruritus, very high bilirubin with delayed surgery, or when neoadjuvant therapy is planned. ERCP with biopsy and stent placement is first-line; if ERCP fails to decompress, PTC/percutaneous biliary drainage is used.

What operation is indicated, and describe the key steps and what defines an adequate oncologic resection.

Expected answer

Pancreaticoduodenectomy (Whipple) for a resectable pancreatic head/periampullary tumor. Key steps: diagnostic assessment for occult metastases, Kocher maneuver, assessment of the SMA/SMV/portal vein for resectability, cholecystectomy and division of the common hepatic duct, division of the stomach/proximal duodenum (or pylorus-preserving), division of the pancreatic neck over the portal vein, and dissection off the SMA with the uncinate. Reconstruction with pancreaticojejunostomy, hepaticojejunostomy, and gastro/duodenojejunostomy. The oncologic goal is an R0 (margin-negative) resection with adequate regional lymphadenectomy.

Intraoperatively at staging you find a small liver surface nodule. What do you do?

Expected answer

I would biopsy the nodule and send for frozen section. If it confirms metastatic adenocarcinoma, the patient has metastatic disease and pancreaticoduodenectomy is contraindicated—I would abort the resection and not perform a Whipple. I would address palliation as needed (biliary and gastric outlet) and refer to medical oncology for systemic therapy. Performing a noncurative Whipple in the face of metastatic disease is a serious error.

How is adjuvant therapy and surveillance managed after a successful R0 resection?

Expected answer

All decisions should be made in a multidisciplinary setting. Adjuvant chemotherapy (e.g., FOLFIRINOX in fit patients, or gemcitabine-based regimens) is standard after resection of PDAC, guided by final pathologic staging and patient performance status. Postoperatively I watch closely for pancreatic fistula, delayed gastric emptying, and bleeding. Surveillance includes clinical follow-up, CA 19-9 trends, and cross-sectional imaging.

What is the prognostic significance of the tumor's site of origin within the periampullary region?

Expected answer

Although all four periampullary cancers arise within 2 cm of the ampulla, prognosis differs significantly by origin and histology. Pancreatic ductal adenocarcinoma has the worst 5-year survival (~17%), followed by bile duct (~23%), ampullary (~37%), and duodenal (~51%). This reflects differences in stage at presentation and the biology of pancreatobiliary versus intestinal histology, which is why pathologic subtyping matters.