PMC6370588_01
Preoperative computed tomography (CT).. Inhomogeneous hypodense ill-defined focal lesion of the head of the pancreas (white arrows) with a dilated intra- and extrahepatic bile duct system due to a mass effect (black arrows) (A transverse image, porto-venous phase; B coronal image, porto-venous phase). Note the healthy adjacent parenchyma of the pancreas (white asterisks) and lack of signs of local irresectability.
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Using contrast-enhanced multi-phase computed tomography (CT), a tumor in the head of the pancreas associated with a distal biliary obstruction was diagnosed suspicious for pancreatic cancer (Fig. 1).
Percutaneous transhepatic cholangiodrainage (PTCD).. Conventional percutaneous cholangiogram with opacification of a dilated intra- and extrahepatic bile duct system (black arrow) with signs of a malignant stenosis at the level of the head of the pancreas (white arrows) (A). Control cholangiogram after positioning of a 8 F PTCD for combined external/internal drainage (black arrow: configuration of the pigtail of the PTCD in the duodenum; white arrows: bridging of the malignant obstruction via the 8 F PTCD) (B).
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Postoperatively, due to persistent jaundice, the patient received percutaneous transhepatic bile duct drainage (PTCD) for combined external/internal drainage which was changed on October 6, 2017 to a self-expanding metal stent (SEMS) for permanent recanalization of the bile duct (Fig. 2).
Computed tomography following PTCD.. Control CT with adequate positioning of the PTCD (black asterisks) and relief of the bile duct system, and constant ill-defined tumor in the head of the pancreas (white arrows) (A transverse image, arterial phase; B coronal image, porto-venous phase).
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The patient again underwent staging, which revealed no signs of liver or lung metastasis (Fig. 3).
Histopathology (hematoxylin-eosin staining).. (A) Histopathology of the pancreatic head following Whipple s procedure reveals an intraductal tubulopapillary neoplasm (ITPN) with typical papillary growth and beginning invasion (arrow). In contrast to IPMN no overt mucin production was observed. (Original magnification, x 25).. (B) Intraductal tubulopapillary neoplasm (ITPN) with associated invasive ductal adenocarcinoma (arrow). (Original magnification, x 25).
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Final histopathology of the surgical specimen surprisingly revealed a pT3, pN0 (0/12), R0, G2 ductal adenocarcinoma arising in the background of an ITPN (Fig. 4).
Hematoxylin-eosin staining and immunohistochemistry with Cytokeratin 7.. (A) Hematoxylin-eosin staining in a higher magnification reveals atypical tumors cells with high-grade dysplasia and a high proliferation rate (arrow). (Original magnification, x 100).. (B) Immunohistochemical staining of the tumor shows ubiquitously positive results for Cytokeratin 7 (CK7) as marked in brown color indicating a highly malignant behavior of the tumor. (Original magnification, x 25).
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Synaptophysin, and Trypsin (Fig. 5). Since the tumor did not show expression of these markers, a neuroendocrine tumor and an acinus cell differentiation were excluded.