PMC5574221_01
Computed tomography findings. (a) Contrast-enhanced computed tomography showed a hypovascular tumor in the pancreatic body and multiple liver masses with marginal enhancement. (b) Positron emission tomography-computed tomography showed accumulation of 18F-fluorodeoxyglucose in the pancreatic body mass [maximum standardized uptake value (SUV max), 7.6], liver masses (SUV max, 9.4), swollen lymph nodes (SUV max, 8.4), and lung masses (SUV max, 1.0).
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Contrast-enhanced CT revealed a pancreatic body tumor with a diameter of 42 mm (Figure 1(a)) and multiple liver masses with marginal enhancement. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography combined with CT showed 18F-FDG accumulation in the pancreatic mass [maximum standardized uptake value (SUV max), 7.6], liver masses (SUV max, 9.4), swollen lymph nodes (SUV max, 8.4), and several lung masses (SUV max, 1.0); however, there were no signs of bone metastasis (Figure 1(b)).
Endoscopic ultrasound findings. A dumbbell-shaped mass was present in the body of the pancreas.
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To obtain a definitive diagnosis, endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was performed using a 22-gauge FNA needle (EchoTip; Cook Medical, Bloomington, IN) (Figure 2).
Pathologic examination findings. (a) Examination of an endoscopic ultrasound-guided fine-needle aspiration specimen showed necrotic tissue and tumor cells with highly atypical nuclei. Based on the histological findings, the final diagnosis was pancreatic adenocarcinoma. (b) Immunohistochemical staining of an endoscopic ultrasound-guided fine-needle aspiration specimen showed strong expression of parathyroid hormone-related protein.
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Histopathologic examination of the biopsy specimen showed necrotic tissue and tumor cells with highly atypical nuclei (Figure 3(a)), indicating a diagnosis of pancreatic adenocarcinoma. PTH-rP concentration was 13.7 pmol/mL, which well exceeded the normal range (<1.1 pmol/mL). Production of PTH-rP by the tumor was confirmed via IHC staining of the pretreatment EUS-FNAB specimen previously obtained; strong expression of PTH-rP in the tissue of pancreatic adenocarcinoma was observed (Figure 3(b)).