Case Discussion
Completion requirements
A 56-year-old school principal from Ilesa presents to the Surgical Oncology Clinic at OAUTHC with two months of weight loss, progressive jaundice, and upper abdominal pain radiating to the back. He also reports pale, bulky stools that float and continued weight loss despite eating well. CT scan shows a 3.4 cm mass in the head of the pancreas. The tumour has 200° involvement of the superior mesenteric artery and 90° contact with the superior mesenteric vein, with no evidence of distant metastases. He had ERCP and his bilirubin falls from 22 mg/dL to 2.5 mg/dL. A biopsy confirms pancreatic ductal adenocarcinoma.
Discussion Prompts
- How would you stage this tumour according to the NCCN resectability criteria? Explain why upfront surgery is not recommended.
- The patient has symptoms of pancreatic exocrine insufficiency. How would you prescribe pancreatic enzyme replacement therapy, and what counselling would you provide regarding its use and affordability?
- Following biliary drainage, his bilirubin has fallen to 2.5 mg/dL. Would you recommend FOLFIRINOX or gemcitabine plus nab-paclitaxel? Justify your choice based on efficacy, toxicity, patient fitness, logistics, and cost.
- His pain remains poorly controlled despite simple analgesics. Outline your approach to pain management, including the role of opioid analgesics and celiac plexus neurolysis.
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