PMC5360961_01
(a) Axial CT demonstrating large mass in body/tail of pancreas before neoadjuvant therapy. (b) Axial CT demonstrating tumor response after neoadjuvant therapy.
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CT with pancreatic protocol revealed an ill-defined soft tissue density in the region of the pancreatic body with proximal pancreatic ductal dilation central necrosis and obliteration of the splenic vein and encasement of the splenic and celiac arteries (Figure 1(a)). At that time, repeat CT imaging showed decrease in the size of her mass and persistent splenic artery encasement but minimal involvement of the celiac artery and findings consistent with possible radiation-induced fibrosis (Figure 1(b)).
Axial, sagittal, and coronal isodose distribution of IMRT plan to 54 Gy in 30 fractions.
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She began neoadjuvant chemotherapy with three cycles of FOLFIRINOX (5-FU, leucovorin, irinotecan, and oxaliplatin) followed by concurrent intensity modulated radiation therapy (IMRT) to a dose of 54 Gy in 30 fractions (Figure 2) and capecitabine, which was tolerated well, except for development of mild peripheral neuropathy.
PET-CT ((a) axial, (b) coronal) images showing lack of FDG-avid uptake in pancreas after neoadjuvant chemoradiation.
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We performed a restaging PET-CT in January 2015, eight months after initiation of therapy, which showed no FDG-avid uptake in the pancreas or the surrounding structures (Figure 3).
Cross sections of gross pathologic specimen. Black arrow points to fibrosis within the body of the resected pancreas. White arrow points to resected adrenal gland. Translucent arrow denotes the splenic artery encased in fibrosis.
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Histopathological analysis revealed an R0 resection with no residual tumor, but extensive fibrosis was found throughout the surgical specimen to the margins (Figures 4 and 5).
(a) H&E sections demonstrating pancreatic tissue with dense fibrosis, residual ducts, and islet cells. No evidence of residual carcinoma. (b) Cluster of islets of Langerhans within the fibrotic tissue.
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Histopathological analysis revealed an R0 resection with no residual tumor, but extensive fibrosis was found throughout the surgical specimen to the margins (Figures 4 and 5).