PMC9393733_01
Time points corresponding to the diagnostic and therapeutic process.
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She presented with intermittent fever without obvious inducement for 3 weeks (specific time points in Figure 1) with the highest temperature of 39 , accompanied by jaundice, occasional nausea, vomiting, and slight discomfort in the right upper abdomen.
Images of the liver and retroperitoneal lymph node lesions were evaluated before and after the operation (new liver and retroperitoneal lymph node lesions after operation, shown by red arrows). (A) CT of liver before the operation; (B) CT of liver was evaluated at baseline after the operation; (C) MRI of the liver was evaluated at baseline after the operation (C1: DWI-b50; C2: T1WI; C3: DWI-b800; C4: T2WI); (D) CT of retroperitoneal lymph nodes before the operation; (E) CT of retroperitoneal lymph nodes was evaluated at baseline after the operation; (F) MRI of retroperitoneal lymph nodes was evaluated at baseline after the operation.
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The intrahepatic and extrahepatic bile ducts and pancreatic ducts were dilated, the gallbladder was enlarged, and no obvious abnormalities of the liver and retroperitoneal lymph nodes were observed (Figures 2A, D). One month after surgery, CT and MRI scan showed multiple hepatic masses (Figures 2B, C) and retroperitoneal enlarged lymph nodes (Figures 2E, F), which were considered metastases.
Pathological morphology (A) (HE x400), expression of positive Alpha-fetoprotein(AFP) staining (B) (SP x100) of tissue samples from presurgical endoscopic ultrasound-guided fine needle aspiration (EUS-FNA); Pathological morphology (C) (HE x400), expression of positive Alpha-fetoprotein(AFP) staining (D) (SP x100) of tissue samples fromsurgery.
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The pathological result of EUS-FNA was moderately to poorly differentiated ampullary adenocarcinoma (Figure 3A); the immunohistochemistry (IHC) of EUS-FNA was AFP (+) (Figure 3B). Postoperative pathology (pancreaticoduodenectomy specimen) (Figure 3C) showed that the duodenal papilla had a poorly differentiated adenocarcinoma, the size of the mass was 4 cm * 2.5 cm * 1.2 cm, and the cancer tissue penetrated the duodenal muscle wall and invaded the pancreatic tissue. Pathological stage was IIIA (T4, N1, cM0); IHC: cancer cell expression CK(+), S100(-), Her2(Sto)(++), COX2(+), VEGFR2(-), EGFR(++), Ki67(about 60%+), P16(focal +), CD56(-), PD-1(-), PD-L1(SP142)(the tumor cells -, interstitial immune cells about 5%+), MLH1(+), MSH2(+), MSH6(+), PMS2(+), c-Met(+), CgA(-); AFP (+) (Figure 3D).
Pathological morphology (A) (HE x100), expression of positive Alpha-fetoprotein(AFP) staining (B) (SP x100) and positive glypican-3(GPC-3) staining (C) (SP x100) in the liver metastases.
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Microscopic observation showed that the tumor cells were distributed in plate shape, and abundant blood sinus structures were seen, adenocarcinoma area and hepatoid differentiation area coexist, polygonal tumor cells with larger volume and eosinophilic cytoplasm can be seen in the hepatoid differentiation area (Figure 4A). Liver biopsy pathology showed adenocarcinoma, poorly differentiated; IHC showed cancer cell expression Hept1 (-), CK19 (+++), CK7 (-), CDX-2 (focal +), Ki67 (70%+), CK20 (-), Villin (+++), Syn (focal +), CgA (focal +), CD56 (focal +); AFP (+), GPC-3 (+) (Figures 4B, C).