A 62-year-old man from Delhi presents with progressive jaundice for 3 weeks, pale stools, and dark urine. He reports a 2-month history of dull epigastric pain radiating to the back, worse at night and unrelieved by antacids. On examination, he is icteric with a palpable, non-tender gallbladder. Laboratory investigations show total bilirubin 8.2 mg/dL (direct 6.8 mg/dL), alkaline phosphatase 320 U/L, and ALT 85 U/L. Abdominal ultrasound reveals dilated intrahepatic bile ducts with a 3 cm hypoechoic lesion in the pancreatic head and no gallstones. CT abdomen confirms a 3.5 cm mass in the pancreatic head with upstream pancreatic duct dilatation ("double duct sign"). There is no evidence of distant metastases. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis & Staging **Key Point:** This patient has a resectable pancreatic head cancer (no distant metastases, no major vascular involvement on imaging). The next step is tissue confirmation via EUS-FNA before committing to surgery or systemic therapy. ### Why EUS-FNA? Endoscopic ultrasound with fine-needle aspiration is the gold standard for obtaining tissue diagnosis in suspected pancreatic cancer because: - High sensitivity (85–95%) and specificity (>95%) for malignancy - Minimally invasive with low morbidity - Allows assessment of vascular invasion and local staging - Guides treatment planning (resection vs. neoadjuvant therapy) - Can be combined with therapeutic interventions (biliary stent placement) **High-Yield:** In a potentially resectable pancreatic cancer, tissue diagnosis MUST precede definitive surgery. EUS-FNA is preferred over ERCP-guided biopsy or CT-guided biopsy because of superior yield and staging detail. ### Management Algorithm for Resectable Pancreatic Cancer ```mermaid flowchart TD A[Suspected pancreatic cancer on imaging]:::outcome --> B{Tissue diagnosis obtained?}:::decision B -->|No| C[EUS-FNA or CT-guided biopsy]:::action B -->|Yes| D{Resectable on imaging?}:::decision D -->|Yes| E[Staging laparoscopy if high risk]:::action E --> F[Pancreaticoduodenectomy]:::action D -->|No| G[Assess for neoadjuvant therapy]:::action G --> H[Chemotherapy ± radiation]:::action H --> I{Resectable after neoadjuvant?}:::decision I -->|Yes| F I -->|No| J[Palliative care / chemotherapy]:::outcome ``` **Clinical Pearl:** The "double duct sign" (dilated common bile duct + dilated pancreatic duct) is highly suggestive of pancreatic head cancer but is NOT pathognomonic — tissue confirmation is mandatory before surgery. **Mnemonic: TISSUE FIRST** — **T**issue diagnosis, **I**maging assessment, **S**taging laparoscopy, **S**urgery (if resectable), **U**ndertake neoadjuvant if borderline, **E** — **F**inal staging, **I**ntent-to-treat, **R**esection or palliation, **S**urvival monitoring, **T**reatment toxicity monitoring.