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A 58 year old man presented with mild cholestasis, with serum alkaline phosphatase 155 U/l (normal 30–120 U/l), serum gamma glutamyl transferase 75 U/l (normal 12–55 U/l), and serum bilirubin 1.45 mg/dl (normal 0.2–1.3 mg/dl). During the previous three months he had lost 2–3 kg in weight but his general state was good with a body mass index of 26 kg/m2.
The patient underwent appendicectomy in his childhood and cholecystectomy for gall bladder stone disease 12 years previously. Eight years before being referred to our institution, he had been nephrectomised for renal cell cancer of the right kidney. The tumour measured 5 cm and microscopically did not infiltrate either the renal capsule or blood vessels (stage T1b, N0, M0). No recurrence was detected during regular follow ups. Five years later in the course of bacterial pneumonia the patient developed acute renal failure which required single haemodialysis. At presentation the patient was not anaemic and his serum creatinine level was 1.36 mg/dl (normal 0.7–1.2 mg/dl).
Ultrasound examination revealed a hypoechogenic mass of the pancreatic head, measuring 4 cm in diameter. On biphasic computed tomography (CT) the pancreatic mass was clearly hypervascular in the arterial phase (fig 1) but in the venous phase its contrast enhancement returned to normal. Radiographically, no other masses were detected, and the peripancreatic lymph nodes were not enlarged. The duodenal wall and peripancreatic tissue were not infiltrated by the tumour. The left kidney was intact on both CT and intravenous urography. Serum concentrations of cancer carcinoembryonic antigen, insulin, serotonin, and gastrin were within the normal range. Fine needle biopsy from the tumour was diagnostically not contributory, showing only desmoplastic fibres and normal glandular cells.
What is the presurgical diagnosis and what is the prognosis in this case?
See page 140 for answer
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