Case Discussion Forum
A 62-year-old retired civil servant from Osogbo presents to the Surgical Oncology Clinic at Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) with progressive painless jaundice and dark, tea-colored urine.Contrast-enhanced CT of the abdomen demonstrates a mass obstructing the ampulla of Vater. She undergoes a pancreaticoduodenectomy (Whipple procedure), and the surgical team achieves an R0 resection. Histopathological examination of the resected specimen presents a management challenge. The local pathology report describes the tumour as a mixed-phenotype adenocarcinoma, demonstrating features of both the intestinal and pancreatobiliary subtypes. She makes an uneventful postoperative recovery and is referred to the medical oncology clinic to discuss adjuvant treatment.
Discussion Prompts
- How would you approach adjuvant treatment for an ampullary adenocarcinoma with mixed intestinal and pancreatobiliary histology? Discuss the role of pathology review, additional immunohistochemistry, and the factors that should guide treatment selection.
- If the tumour is confirmed to be of the pancreatobiliary subtype, which adjuvant chemotherapy regimen would you recommend? Justify your recommendation using current evidence and clinical practice guidelines.
- The patient asks whether she could receive targeted oral therapy instead of conventional intravenous chemotherapy to reduce hospital visits. Which predictive molecular biomarkers should be tested on the surgical specimen, and how would the results influence the use of targeted therapies or immunotherapy?
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