Patient demographics | M, 64 yrs.; married |
Status praesens | Nausea and pain in the upper abdomen, back pain, unintended weight loss of 6 kg, condition stable, but generally restricted. |
Past medical history (PMH) | Three-vessel CAD; s/p CABG occasionally AP on exertion-controlled arterial hypertension, COPD GOLD II, under medication. |
Family history (FH) | Unknown |
Social History (SH) | Smoker (60 pack-years), lives at home with his wife who supports him with domestic activities; he formerly worked as a butcher, now unfit for work. |
Allergies (ALL) | None |
Physical examination (PE) and test results | - Slightly diminished general condition, BMI 27, 3, 140/95, heart and lungs: NAD, neurology: NAD - Endoscopic ultrasound: mass located in the pancreatic head, inhomogeneous - MRI scan abdomen: 3.5 cm mass in processus uncinatus, multiple peripancreatic lymph nodes - MR angiography: primary cancer not resectable: full vessel involvement and infiltration of SMA - Histology (endosonography): high-grade pancreatic ductal adenocarcinoma, no metastases detected - LAB: Hemoglobin 13.2 g/dl; Leukocyte 5200/μl; Thrombozyten 150,000/μl Creatinin: 1.2 mg/dl Bilirubin: 1.1 mg/dl Amylase: 100 U/l Lipase: 55 U/l CA19–9 (carbohydrate antigen 19.9): 1350 U/ml |
Diagnosis | Locally advanced, pancreatic ductal adenocarcinoma cT4N1M0 (UICC stage III) |