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A presenting with obstructive jaundice in pulmonary adenocarcinoma: a case report.

INTRODUCTION
Obstructive jaundice caused by metastases to the distal common bile duct or the ampulla of Vater is often observed in patients with various advanced cancers; however, metastasis of lung cancer to the ampulla of Vater with subsequent development of jaundice is rare.


CASE PRESENTATION
The patient was a 41-year-old Chinese female who presented with apparent jaundice and itching. An enlarged right supraclavicular lymph node was found during physical examination. Laboratory tests revealed significantly elevated bilirubin and aminotransferase. Imaging examinations, including ultrasonography, computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP) revealed a 3.1×2.5×2 cm mass in the distal common bile duct and the ampulla of Vater. The routine chest x-ray film revealed a 4-cm nodule in the upper lobe of the left lung and further CT scan confirmed the diagnosis of left lung cancer. A biopsy of supraclavicular lymph node was performed and the histopathology showed poorly differentiated adenocarcinoma with cytokeratin-7 (CK-7) and thyroid transcription factor-1 (TTF-1) being positive immunohistochemically. The patient underwent a pylorus preserving pancreaticoduodenectomy and the histology of the resected specimen revealed characteristic of pulmonary adenocarcinoma. Thus, the final diagnosis was periampullary metastasis from pulmonary adenocarcinoma. The patient's postoperative recovery was uneventful and the jaundice was disappeared one month later. A pulmonary lobectomy was followed by chemotherapy with combination of vinorelbine and cisplatin for six cycles.


CONCLUSION
Similar situations are bound to occur again in the future and we believe that this report could demonstrate that there is a case for aggressive surgical management in patients with periampullary metastasis from pulmonary adenocarcinoma.