PMC7434513_01
A) Arterial phase CT scan. Multiple cysts (arrow) which replace pancreatic parenchyma. B) Magnetic resonance imaging, T1 weighted sequence, without contrast demonstrates hypointense focal images and others of different sizes which are hyperintense (arrows). C) The T2 weighted sequence shows hyperintense cystic focal images and others which are heterogeneously hyper and hypointense consistent with the image descriptions in B (arrow). D) Cholangioresonance shows dilatation of the bile duct with a blockage in the intrapancreatic bile duct and the disappearance of the Wirsung duct by replacement of the pancreatic parenchyma by the tumour.
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figure1
The study of ultrasound, computed tomography (CT scan) and magnetic resonance imaging showed a voluminous lesion both solid and cystic in the head of the pancreas extending throughout the body and tail, accompanied by multiple hepatic images suggestive of secondaries (Figure 1A-C). The magnetic resonance cholangiopancreatography showed marked intra- and extrahepatic dilation of the bile duct in relation to the expansive formation described previously (Figure 1D).
PMC7434513_02
Endoscopic Ultrasound (EUS). A) Hypoechoic heterogeneous mass, with irregular borders, located in the head of the pancreas. B) Observe the distal end of the biopsy needle entering the tumour (yellow arrow).
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On the EUS, a hypoechoic mass with heterogeneous echotexture was identified at the level of the head of the pancreas, measuring 52 x 50 mm in contact with the splenoportal axis and invasion of the distal bile duct (Figure 2).
Undifferentiated carcinoma with osteoclast-like giant cells coloured with haematoxylin and eosin. A) Epithelioid component of the carcinoma with glandular pattern associated with OGC (arrow). B) Spindle cell component of the carcinoma. C, D and E) High magnification of A and B. C) Adenocarcinoma, D) Spindle cell component and E) OGC. Original magnification: 100x (A, B); 400x (C, D and E). Ref: OGC: osteoclast-like giant cells.
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figure3
The histological sections of the material embedded in paraffin and coloured with haematoxylin and eosin, showed a neoplastic proliferation constituted by cells with marked atypia, arranged in cords and duct-like structures (Figure 3A and C). In some areas, this lesion acquired a spindle cell pattern with marked pleomorphism (Figure 3B and D). The neoplasia was accompanied by numerous OGC (Figure 3E), extensive areas of necrosis and haemorrhage.
Immunohistochemical techniques. A) Intense positivity with the cytokeratin cocktail (pan keratin) in the epithelioid and spindle cell components of the tumour. B and C) High magnification of the spindle cell component where coexpression of pan keratin (B) and vimentin (C) can be identified. D) Positivity with CD68 in the OGC and the histiocytes. E and F) Overexpression of p53 in the neoplastic epithelial (E) and spindle cell components (F). Original magnification: 40x (A); 100x (B, C, D, E and F). Ref: OGC: osteoclast-like giant cells.
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figure4
In the epithelioid component, intense positivity was observed with the cytokeratin cocktail and with cytokeratin 7 (Figure 4A). The spindle cell component coexpressed cytokeratins and vimentin (Figure 4B and C) and negativity with smooth muscle actin and S100 protein. The OGC and the histiocytes were positive for CD68 (Figure 4D). The p53 protein was overexpressed in both epithelial and spindle cell neoplastic components, but was negative in the OGC and histiocytes (Figure 4E and F).