Brief Answer:
Biopsy confirmation of cancer is important

Detailed Answer:
Hi XXXX,
Thanks for writing in to us.

I have read through your query in detail.
The attached reports have been seen by me. I have worked in a cancer hospital for some years and have seen a lot of cancer patients.

The echocardiography report shows age related changes which can be expected at 85 years.

The other two reports (ultrasound and MRI with MRCP) are important.

First analyzing the ultrasound report, diagnosis of atrophic pancreatitishas been made with the presence of dilated main pancreatic duct and dilated common bile duct (CBD) and intrahepatic biliary radicals (IHBR).

This shows that there is some block of bile when flowing from the liver to the intestine. However, ultrasound may not always see a mass (cancer) in the region of pancreas due to the presence of gas and that is the reason no cancer has been mentioned.

The kidney stones and urinary bladder stone with prostate enlargement are not significant at the moment.

Coming to the MRI with MRCP
There is a mass in the head of pancreas which is causing obstruction to flow of bile from liver through common bile duct. The size of the mass should have been mentioned for better understanding. This mass has been considered as a cancer in the pancreas.

Now coming to our discussion, when such a mass is not seen on ultrasound but well seen on MRI then the MRI report is considered. Truly speaking, this mass should be confirmed as a cancer by doing ultrasound or CT scan guided biopsy (depending on the size and location). Only once it is confirmed a cancer by biopsy, should the diagnosis of cancer be made, even though the mass might look like a cancer.

Coming to treatment options, if it is confirmed to be a cancer then it is better to leave the patient alone and put him on pain relief medicines and he may live for 6 months. Surgery in infiltrating pancreas cancer can cause faster spread of disease and kill the patient and is not recommended.

There is no mention of any problem with testes in any of the reports.

My final suggestion is that first you get a biopsy done from the mass in head of pancreas at a hospital having cancer treatment facilities and then confirm if it is a cancer. If confirmed then most likely the doctors will give pain relief medications and treat as per standard procedures. You must take care of his nutrition and general health condition.

Hope this answers your question. Please feel free to correct any oversight in my interpretation of your problems and discuss them in detail as per your requirements.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

---

Brief Answer:
1.6cm is common bile duct measurement and not mass

Detailed Answer:
Hi XXXXXXX
Thanks for writing in with an update.

I have noticed the observation made by you but would like to clarify that 1.6 cm is the diameter of the distal common bile duct and not the mass.

Please let me explain this in detail from basics.

The gall bladder stores bile which helps in digestion. The bile exits the gall bladder through the cystic duct. The cystic duct then joins the common bile duct through which the bile is transported to the duodenum or small intestine. The opening of the common bile duct into the duodenum is called ampulla of vater. The common bile duct has got a proximal (upper half) and distal (lower half) portions. The lower half of common bile duct passes through the head of pancreas as it enters the duodenum. A tumour or cancer can develop anywhere along the course of the common bile duct.

Patients with distal bile duct cancer presents with symptoms that are similar to that of pancreatic cancer and ampullary cancer. Distal bile duct tumours, pancreatic cancer and ampullary cancer are often called periampullary tumours because all three present with similar symptoms. It is important to recognize bile duct cancer and ampullary cancer since the outcome of the two cancers is better than that for pancreatic cancer when patients are compared stage for stage.

Your grandfather has probably got a mass in or around the lower half of common bile duct, also known as distal common bile duct tumour and such a tumour is often closely associated with the head of pancreas. Due to this tumour, there is pressure on the distal common bile duct and it is given as enlarged (dilated) measuring 1.6 cm. At 85 years, the common bile duct should measure 0.8 to 0.9 mm and now it is about twice the diameter due to the mass causing pressure on its lower end.

As per present medical practices on distal common bile duct cancers, the following are the treatment guidelines.

"Once the diagnosis of bile duct cancer is made, the patient requires a work up for surgical removal of the tumor if in early stages. Complete removal of the tumor is the only effective and potentially curative treatment for cancers of the lower bile duct.

In patients with advanced distal bile duct cancer that is not surgically removable the goal of treatment is palliation. The most important palliative measure is the relief of jaundice. A wall stent placed by a gastroenterologist provides adequate biliary drainage to relieve the obstruction and relieve jaundice. Surgically unresectable distal bile duct cancers do not usually respond very well to chemotherapy and radiation therapy therefore treatment options are limited."

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

---

Brief Answer:
Kidney problems must be treated first

Detailed Answer:
Hi XXXXXXX
Thanks for writing back with an update.

As discussed earlier, without knowing the size of the mass and doing a biopsy, it is difficult to confirm a cancer. Your grandfather does not have jaundice even in reports. This raises concern if the mass is a cancer or not.

Jaundice can be from a tumor in the head of the pancreas blocking the normal flow of bile into the small intestine by causing compression of the common bile duct. However, many patients with pancreatic cancer do not have jaundice when the cancer is diagnosed it there is no obstruction to flow of bile. Pain and weight loss are also significant symptoms in pancreatic cancer.

The sodium and potassium levels in the reports are normal and not a worry. However if any latest report shows abnormal sodium or potassium, it can be corrected by giving fluids containing the electrolytes.

It is seen that his kidney function tests are abnormal. This is seen from high blood urea and serum creatinine levels in blood. This needs a consultation with nephrologist and all attempts have to be made to get back kidney functions to normal. This is important because if creatinine goes up further then other organs will also be affected. I think this is the reason the doctors are telling he is seriously ill. This can happen due to many reasons like kidney infection, urinary obstruction, dehydration, high blood pressure and diabetes. This might have happened after admission to hospital.

His blood hemoglobin is also slightly below normal.

In my opinion, first we need to treat the abnormal kidney function and then think about the possible cancer. To begin with you can consult a nephrologist (doctor who treats kidney problems) and a cancer surgeon in any reputed hospital in your area and then decide further actions. You can go and meet doctors with reports and patient need not be taken for the first visit. If you do not have such doctors in your town then you can go to good hospitals in XXXXXXX or XXXXXXX

Every attempt must be made to treat the kidney function right now.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

---