PMC7322239_01
Computed tomography (CT) scan showing pancreatic head tumor (red arrow heads) causing dilatation of biliary and pancreatic ducts. A: axial view; B: coronal view.
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An abdominal computed tomography (CT) scan revealed a hypo-vascular mass with 16-mm in diameter located in the head of the pancreas causing dilatation of biliary and pancreatic ducts (Fig. 1A, B).
Computed tomography (CT) scan showing swellings of distant lymph nodes (red arrow heads). A: para-aortic lymph nodes (red arrow heads); B: left supraclavicular node (red arrow heads).
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The swelling of multiple para-aortic lymph nodes and a left supraclavicular lymph node (Virchow's node) was also observed (Fig. 2A, B).
Histopathological findings of biopsy specimen consistent with well differentiated adenocarcinoma (hematoxylin-eosin staining). A: low magnification; B: high magnification.
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The result of biopsy was concordant with well differentiated tubular adenocarcinoma (Fig. 3A, B).
Transition graph of serum carbohydrate antigen 19-9 (CA19-9) level and the treatment progress.
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Serum CA19-9 level was sharply decreased to 7543.2 U/mL (almost 90% reduction) (Fig. 4). A CT scan revealed that shrunken lymph nodes had remained stable, and serum CA19-9 level became almost normal (38.5 U/mL) (Fig. 4).
Computed tomography (CT) scan after FOLFIRINOX (combination of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) treatment showing only tiny appearances of distant lymph nodes. A: para-aortic lymph nodes (red arrow heads); B: left supraclavicular lymph node (a red arrow head); C: primary lesion (red arrow heads).
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As to primary lesion, significant uptake was not observed in PET-CT although hypo-vascular mass remained left side of the metallic stent (Fig. 5C, 6C).
Positron emission tomography (PET)-CT scan just before conversion surgery showing no distant metastases. A: para-aortic lymph nodes; B: left supraclavicular lymph node; C: primary lesion.
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A positron emission tomography (PET)-CT scan also showed no abnormal uptake in distant lymph nodes (Fig. 6A, B). As to primary lesion, significant uptake was not observed in PET-CT although hypo-vascular mass remained left side of the metallic stent (Fig. 5C, 6C).
Surgical specimen of subtotal stomach preserving pancreaticoduodenectomy (A) and an intraoperative picture after dissection of para-aortic lymph nodes (B).
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Given these results, and after discussion at multidisciplinary cancer conference, the patient underwent subtotal stomach preserving pancreaticoduodenectomy with dissection of para-aortic lymph nodes 8 months after the initiation of chemotherapy (Fig. 7A, B).
Histopathological findings of surgical specimen showing scattered foci of grade IB pancreatic intraepithelial neoplasia (hematoxylin-eosin staining, x100) (a white arrow).
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Histopathological examination of the surgical specimen showed no evidence of residual adenocarcinoma in neither pancreas head nor 54 dissected lymph nodes including para-aortic nodes, although scattered foci of grade IB pancreatic intraepithelial neoplasia were observed (Fig. 8).