question: Q:A 66-year-old man comes to the physician because of yellowish discoloration of his eyes and skin, abdominal discomfort, and generalized fatigue for the past 2 weeks. He has had dark urine and pale stools during this period. He has had a 10-kg (22-lb) weight loss since his last visit 6 months ago. He has hypertension. He has smoked one pack of cigarettes daily for 34 years. He drinks three to four beers over the weekends. His only medication is amlodipine. His temperature is 37.3°C (99.1°F), pulse is 89/min, respirations are 14/min, and blood pressure is 114/74 mm Hg. Examination shows jaundice of the sclera and skin and excoriation marks on his trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show:
  Hemoglobin 12 g/dL
  Leukocyte count 5,000/mm3
  Platelet count 400,000/mm3
  Serum
  Urea nitrogen 28 mg/dL
  Creatinine 1.2 mg/dL
  Bilirubin
  Total 7.0 mg/dL
  Direct 5.5 mg/dL
  Alkaline phosphatase 615 U/L
  Aspartate aminotransferase (AST, GOT) 170 U/L
  Alanine aminotransferase (ALT, GPT) 310 U/L
  γ-Glutamyltransferase (GGT) 592 U/L (N = 5–50 U/L)
  An ultrasound shows extrahepatic biliary dilation. A CT scan of the abdomen shows a 2.5-cm (1-in) mass in the head of the pancreas with no abdominal lymphadenopathy. The patient undergoes biliary stenting. Which of the following is the most appropriate next step in the management of this patient?"? 
  {'A': 'Stereotactic radiation therapy', 'B': 'Gastroenterostomy', 'C': 'Pancreaticoduodenectomy', 'D': 'Gemcitabine and 5-fluorouracil therapy', 'E': 'Central pancreatectomy'},