A 76-year-old woman with no history other than hypertension consults for painless jaundice and pruritus with anorexia. Laboratory tests show a bilirubin level of 12 mg/dl (with 9.5 direct bilirubin). Abdominal ultrasound shows dilatation of the intrahepatic and extrahepatic biliary tract, together with a single 2 cm nodule located peripherally in the anterior aspect of the left lobe. CT scan confirms the findings, also demonstrating the presence of a 3.5 cm mass in the head of the pancreas. Fine needle aspiration confirms the diagnosis of adenocarcinoma. Indicate the best therapeutic option:
I think the correct answer is 4, although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity. Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma.
Adjuvant chemo/radiotherapy, conditioning radical surgery to the initial response.
Percutaneous external drainage is palliative, with eventual conversion to internal drainage in case of intolerance or complications.
Surgical biliary bypass, with or without prophylactic gastrojejunostomy depending on intraoperative findings.
Metallic biliary prosthesis by endoscopic retrograde cholangiography, with the option of palliative chemotherapy.
Cephalic duodenopancreatectomy with radiofrequency ablation or alcoholization of the liver lesion.
I think the correct answer is 4, although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity.