Sample Case
The following is an example of an MDExpert second opinion

MDExpert believes that the best second opinion is one received at a major cancer center where a physical examination and direct interaction with a physician are part of the overall assessment. MDExpert uses information from previous doctor visits and studies to augment care with written opinions from leading academic experts in appropriate oncology specialties.

CASE: 58-year-old male with newly diagnosed cholangiocarcinoma.

DIAGNOSIS: Cholangiocarcinoma

HISTORY OF PRESENT ILLNESS:The patient is a 58 year old Hispanic man who first presented about 4 weeks prior to admission with severe diarrhea, abdominal pain, weight loss, anorexia, and jaundice in association with dark urine and light colored stool. He was positive for Hep A IgM Ab at that time. Over the next 2-3 weeks, his diarrhea resolved but his other symptoms persisted and he continued to lose weight. He then presented to the Emergency Room on 7/12/00 with dizziness, hypotension and severe anorexia. He was admitted for evaluation.

Admission laboratory studies showed:Total bilirubin: 23.6

Alkaline Phosphatase: 371

AST: 118

ALT: 135

Amylase: 62

HgB: 11.5

Abdominal CAT scan performed on the day of admission showed intra- and extrahepatic bile duct dilatation and a distended gall bladder with no identifiable masses. Subsequent ERCP (7/14) showed slight dilatation of the pancreatic duct at the head, and inability to cannulate the Common Bile Duct. Esophagogastroduodenoscopy (7/14) showed a normal appearance to the 1^st and 2^nd portions of the duodenum. Percutaneous transhepatic cholangiogram (7/14) showed dilation of the right and left biliary ducts, dilation of the common bile duct with 3-4 cm segment of obstruction. A biliary drainage catheter was successfully placed, and brush biopsies were taken. These cytologies were negative for malignancy.

On 7/22 the patient was taken for exploratory laporotomy. Mild hepatosplenomegaly was noted, the bowel was normal, and there was no evidence of metastatic disease. Because the patient had a large edematous pancreas with evidence of acute pancreatitis, he was reclosed.

His post-operative course was complicated by respiratory failure requiring intubation, possible ARDS, and sepsis (lactobacillus cultured from blood). He underwent 2 further laporotomies. Intraabdomial bleeding was seen but the source was not identified. Cytologic washings were negative for malignancy.

Once the patient was stabilized, further evaluation was performed. Repeat cholangiogram (8/21) showed occlusive obstruction of the common bile duct, and fluoroscopic percutaneous biopsy of the common bile duct performed 8/21 was positive for adenocarcinoma. In addition, a biliary stent was successfully placed for drainage.

The patient was discharged, eating well, and with plans to come back for a Whipple procedure once his albumen rises. Discharge albumen was 1.7. Admission albumen is not available. Albumen on 7/25 was 2.4.

PAST MEDICAL HISTORY:

• Diabetes
• Hypertension
• Rheumatoid arthritis
• Smoking history — 3ppd x 35 yrs; none for 6 yrs

PAST SURGICAL HISTORY:

• Tonsillectomy
• Left knee replacement, 1995
• Amputation of distal rt phalanx

• None known

MEDICATIONS:

• Glucophage
• Amaryl
• Lotensin
• Ecotrin

SOCIAL HISTORY:

The patient is married with 6 children. He is disabled secondary to arthritis and diabetes.

FAMILY HISTORY:

Positive for paternal diabetes and maternal breast carcinoma

REVIEW OF SYSTEMS:

History of benign ventricular arrhythmias

PERTINENT PHYSICAL FINDINGS:

• BP 130/55, P55
• Mild epigastric tenderness with no palpable masses of hepatosplenomegaly

LABORATORY STUDIES:

• CA 19-9: 195
• CEA: 3.7
• Discharge Alb: 1.7
• Discharge HgB: 10.5

RADIOGRAPHIC/DIAGNOSTIC STUDIES:

• Abdominal CAT scan, 7/12/00 — intra- and extrahepatic duct obstruction, distended gallbladder; no masses seen
• ERCP, 7/14/00 — mild dilation of pancreatic duct in head of pancreas; unable to cannulate CBD
• Cholangiogram, 7/14/00- 3-4 cm of obstructed CBD and right and left biliary duct dilation; brush biopsies negative for malignancy
• Exploratory laporotomy, 7/22/00 — acute pancreatitis, mild hepatosplenomegaly, no metastatic disease noted
• Fluoroscopic percutaneous bile duct biopsy with cholangiogram, 8/21/00 — positive for adenocarcinoma

PATHOLOGY REPORTS:

• Brush biopsies, common bile duct, 7/14/00 — negative for malignant cells
• Pancreatic washings, 7/14/00 — negative for malignant cells
• Bile fluid — 8/9/00 — negative for malignant cells
• Bile fluid — 8/11/00 — negative for malignant cells
• Percutaneous needle biopsy, common bile duct, 8/21/00 — positive for adenocarcinoma, grade not noted.

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