PMC9283868_01
CT images of pancreatic lesions during concurrent chemo-radiotherapy followed by sequential chemotherapy, with red arrows indicating the location of pancreatic head lesions. (A) The initial CT examination revealed a mass in the head of the pancreas, about 3.6 x 3.5 cm. (B) After concurrent chemo-radiotherapy, the pancreatic head cancer lesion did not change much compared with the previous, about 3.9 x 3.3 cm. (C-E) One to six cycles of sequential chemotherapy with gemcitabine + TS-1 gradually reduced the pancreatic head lesion and the efficacy evaluation was PR.
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The blurred demarcation between the mass of the pancreas head and the superior mesenteric artery and vein indicated local advanced stage ( Figure 1A ). Figure 1B ), suggesting stable disease (SD). From The results of abdominal CT in the follow-up period on March 14, 2020, showed that the pancreatic head cancer lesion had decreased to the size of approximate 1.1 cm x 0.9 cm ( Figures 1C-E ).
In the HE staining pictures, the tissue at the upper edge of the pancreas was shown, no normal pancreatic structure was seen, and irregular carcinomatous glandular infiltration was observed. Glandular epithelial cells were enlarged, varying in size, crowded, and disorganized. Nuclei were enlarged and irregular, chromatin was thickened. Stroma was present, accompanied by significant fibrogenic response.
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The pathological findings revealed invasive or metastatic adenocarcinoma in the fibrous tissue (lymph nodes at the upper edge of the pancreas,  Figure 2 ). Cholecystojejunostomy, abdominal lymph node biopsy as well as abdominal adhesiolysis were performed. Conclusively, combined with the patient's medical history, laboratory test (CA19-9 significantly increased), imaging examination (pancreatic head mass shadow lacked blood supply, and pancreaticobiliary duct significantly dilated, presenting "double tube sign"), pathological findings ( Figure 2 ), the disease of the patient was diagnosed as pancreatic head adenocarcinoma with abdominal lymph node metastasis (pT4N2M0, stage III), which was confirmed after palliative surgery.
CT images of pancreatic cancer lesion during first-line treatment, red arrow indicates pancreatic lesion. (A) The results of CT reexamination 3 months after the end of sequential chemotherapy showed a slightly enlarged pancreas head mass, prior to AG regimen treatment. (B) The results of CT after two cycles of AG regimen treatment showed significantly enlarged pancreatic head mass compared with that before treatment.
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The results of abdominal CT in follow-up on June 29, 2020, showed that the pancreatic head mass was larger than the previous, about 1.0 cm x 2.3 cm ( Figure 3A ). The results of CT examination in follow-up on October 12, 2020, showed that the pancreatic head mass was significantly larger than before, about 2.4 cm x 4.3 cm ( Figures 3B ,  4A ), and then second-line treatment was initiated.
CT images of the pancreatic head lesion in the second-line course with red arrows indicating the location of the pancreatic head lesion. (A) Before anlotinib-targeted therapy combined with TS-1, the tumor size was about 2.4 cm x 4.3 cm. (B) CT after three cycles of anlotinib targeted therapy combined with TS-1 showed that the pancreatic head tumor was reduced to approximate 2.5 cm x 3.3 cm. (C) CT after eight cycles of anlotinib targeted therapy combined with TS-1 showed that the pancreatic head tumor was slightly enlarged compared with that after three cycles of treatment, about 4.2 cm x 3.1 cm. (D) CT showed no significant change in the size of the pancreatic head tumor after adjusting the anlotinib dose for two cycles. (E) After three cycles and (F) five cycles, CT showed that the pancreatic head tumor was slightly larger than the previous, about 4.3 cm x 3.1 cm. (G) CT image after adjusting the dose of anlotinib for six cycles showed no significant change in the size of the pancreatic head tumor compared with the previous, and the efficacy was evaluated as SD.
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The results of CT examination in follow-up on October 12, 2020, showed that the pancreatic head mass was significantly larger than before, about 2.4 cm x 4.3 cm ( Figures 3B ,  4A ), and then second-line treatment was initiated. TS-1 40 mg bid po d1-d14, anlotinib 8 mg qd po d1-d14, q3w. After three cycles, the results of CT reexamination on December 29, 2020 showed that the pancreatic head mass had reduced size to 2.5 cm x 3.3 cm ( Figure 4B ). The results of the CT examination in follow-up on April 20, 2021, after eight cycles showed: Pancreatic head mass was slightly enlarged, about 4.2 cm x 3.1 cm ( Figure 4C ). During this period, the results of CT reexaminations for three times showed that the pancreatic head mass was overall stable ( Figures 4D-F ), and the signs of local radiotherapy was observed and evaluated by the radiotherapy department. After radiotherapy, the results of the CT reexamination on November 5, 2021, showed that the pancreatic head mass did not change much compared with the previous, about 4.3 cm x 3.1 cm ( Figure 4G ).
Flowchart of the patient's treatment history.
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The patient's treatment history is shown in  Figure 5 .
MRCP images before treatment.
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The MCPR image of the patient before treatment is shown in  Figure 6  as a reference.