What is the recommended treatment plan for a patient with a periampullary mass lesion, dilated bile ducts, and enlarged lymph nodes, as seen on a Contrast-Enhanced Computed Tomography (CECT) scan, considering the patient's age, medical history, and performance status?

Management of Periampullary Mass with Biliary Obstruction

This patient requires pancreatoduodenectomy (Whipple procedure) as the definitive treatment, preceded by comprehensive staging to confirm resectability and exclude metastatic disease. 1

Immediate Diagnostic Priorities

Complete Staging Workup Required

The imaging findings suggest a distal cholangiocarcinoma or ampullary carcinoma, both of which are managed surgically with pancreatoduodenectomy when resectable. 1 Before proceeding to surgery, you must complete staging:

• MRI with MRCP is essential to better delineate tumor extent, vascular involvement (portal vein, superior mesenteric vessels), and assess for liver metastases that CT may have missed 1, 2
• Chest CT to exclude pulmonary metastases 1
• Staging laparoscopy should be strongly considered to detect peritoneal metastases, which are present in 10-20% of patients at presentation and would preclude curative resection 1

Tissue Diagnosis Considerations

Do NOT perform percutaneous biopsy of this potentially resectable lesion due to tumor seeding risk. 1, 2 The definitive pathology will be obtained at surgery. 1

However, if you need biliary decompression for cholangitis or if staging reveals unresectable disease, proceed to ERCP with brush cytology and biopsy (combined yield 40-70% sensitivity). 1, 2 Reserve ERCP for therapeutic decompression or when surgical resection is not planned. 1

Tumor Markers

Check CA 19-9, CEA, and CA 125 immediately for prognostic information and baseline values for surveillance. 3, 2 CA 19-9 >100 U/mL has 75% sensitivity and 80% specificity for cholangiocarcinoma, though it can be elevated in benign biliary obstruction. 3, 2

Surgical Management for Resectable Disease

Resectability Criteria Assessment

The enlarged lymph nodes (12-14mm) in periportal and peripancreatic regions are concerning but do not automatically preclude resection. 1 Lymph node involvement is present in 50% of patients at presentation, and distal cholangiocarcinomas/ampullary cancers can still achieve 20-30% five-year survival even with regional nodal disease. 1

Absolute contraindications to resection include:

• Distant metastases (liver, peritoneum, distant lymph nodes) 1
• Encasement of superior mesenteric artery or celiac axis 4
• Portal vein involvement may be resectable with vascular reconstruction in select cases 4

Surgical Procedure

Pancreatoduodenectomy (Whipple procedure) is the standard operation for distal bile duct and periampullary tumors. 1, 4 This includes:

• En bloc resection of pancreatic head, duodenum, distal bile duct, and gallbladder 1
• Regional lymphadenectomy (periportal, peripancreatic, celiac nodes) 1
• Reconstruction with hepaticojejunostomy, pancreaticojejunostomy, and gastrojejunostomy 1
• Goal is tumor-free margin >5mm (R0 resection) 1

Patient suitability should be guided by medical risk factors and performance status rather than age alone. 1

Management if Unresectable

If staging reveals unresectable disease (peritoneal metastases, distant spread, or vascular involvement precluding resection):

• Biliary decompression via ERCP with metal stent placement for symptomatic obstruction 1
• Palliative chemotherapy with gemcitabine-based regimens 5
• Consider gastrojejunostomy if duodenal obstruction is present or anticipated 4

Critical Pitfalls to Avoid

Do not delay surgical evaluation in a patient with potentially resectable disease. The 23mm periampullary mass with dilated bile ducts and regional adenopathy requires urgent multidisciplinary assessment. 1

Do not assume enlarged lymph nodes mean unresectable disease. Abdominal lymphadenopathy can be reactive, and regional nodal involvement does not preclude curative resection for distal cholangiocarcinoma or ampullary cancer. 1, 6

Exclude other primary malignancies that can mimic cholangiocarcinoma, particularly pancreatic adenocarcinoma (requires EUS), gastric cancer (requires endoscopy), and lymphoma (younger patients, homogeneous enhancement pattern). 1, 7, 8

Ensure adequate biliary drainage before major surgery if cholangitis is present, as inadequate drainage increases perioperative sepsis risk. 1