A 64-year-old smoker presents with 6 weeks of progressive painless jaundice, dark urine, pale stools, and pruritus. He has lost 8 kg and developed new-onset diabetes. On examination, a non-tender gallbladder is palpable. Triple-phase pancreatic protocol CT shows the structure marked **A** — a 3.2-cm hypoattenuating mass in the pancreatic head — with simultaneous dilation of the common bile duct (18 mm) and main pancreatic duct (8 mm), plus upstream pancreatic atrophy. There is no vascular encasement or distant metastasis. EUS-FNA confirms pancreatic ductal adenocarcinoma. Which of the following is the most appropriate next step in management?

Question

Accepted Answer

C. Pancreaticoduodenectomy (Whipple procedure) with adjuvant modified FOLFIRINOX × 6 months. ## Why option 1 is correct

The hypoattenuating mass marked **A** in the pancreatic head with the pathognomonic double-duct sign (dilated CBD and main pancreatic duct due to mass effect at the ampulla), combined with absence of vascular encasement or metastasis, indicates RESECTABLE pancreatic ductal adenocarcinoma. Per Bailey & Love 28e and current NCCN/ESMO guidelines, resectable disease is managed with upfront PANCREATICODUODENECTOMY (Whipple procedure) — en-bloc resection of pancreatic head, duodenum, gallbladder, distal CBD, and proximal jejunum with reconstruction. Routine preoperative biliary stenting is NOT recommended (increases infectious complications per DROP trial) unless there is cholangitis, severe pruritus, or surgical delay > 2 weeks. Adjuvant modified FOLFIRINOX × 6 months is the preferred chemotherapy in fit patients (PRODIGE-24 trial: median OS 54 vs 35 months with gemcitabine + capecitabine), significantly improving survival in resectable disease (25–30% 5-year survival vs < 10% without adjuvant therapy).

## Why each distractor is wrong

- **Option 2 (ERCP + stent then neoadjuvant FOLFIRINOX)**: Neoadjuvant chemotherapy is reserved for borderline resectable or locally advanced disease with vascular involvement. This tumor is fully resectable with no encasement; routine preoperative stenting is not indicated and increases infection risk. Upfront surgery is standard.
- **Option 3 (Palliative gemcitabine + nab-paclitaxel)**: This regimen is for metastatic disease. The CT shows no liver, peritoneal, or distant metastasis; the tumor is resectable and curative intent surgery is indicated.
- **Option 4 (PTC with external drainage)**: PTC is reserved for unresectable/palliative cases or when ERCP fails. Resectable disease requires definitive surgical resection, not drainage alone.

**High-Yield:** Double-duct sign (dilated CBD + main pancreatic duct) in a hypoattenuating pancreatic head mass = resectable pancreatic adenocarcinoma → Whipple + adjuvant FOLFIRINOX; routine preoperative stenting increases infection risk and is NOT recommended unless cholangitis or surgical delay.

[cite: Bailey & Love 28e, Pancreas; PRODIGE-24 trial (Conroy et al. 2023); DROP trial]

Answer

A. Endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent followed by neoadjuvant FOLFIRINOX

Answer

B. Palliative gemcitabine + nab-paclitaxel chemotherapy with best supportive care

Answer

D. Percutaneous transhepatic cholangiography (PTC) with external drainage and observation

Explanation

Why option 1 is correct

Why each distractor is wrong

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