PMC3388274_01
a Endoscopic finding obtained when endoscopic nasal biliary drainage was switched to endoscopic retrograde biliary drainage at our hospital. A depressed lesion was visible at the distal side of the papillary opening. The lesion was hemorrhagic fragile mucosa. b Biopsy of this site allowed a diagnosis of moderately to well-differentiated adenocarcinoma. c, d Findings from abdominal CT scans upon admission. c CT scans at the level of the duodenal papilla revealed no primary tumor. There was no marked dilatation of the main pancreatic duct or common bile duct. No space-occupying region suggesting metastasis was seen in the liver. No sign of ascites was noted. d Swelling of the lymph nodes around the aorta, like the ones shown here, was visible at the celiac artery level to the level of the common iliac artery bifurcation.
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F1
Endoscopy revealed early-stage cancer (IIa + IIc) distal to the duodenal papilla (fig. 1a), and biopsy allowed a diagnosis of well-differentiated adenocarcinoma (fig. 1b). CT revealed a large number of lymph node metastases around the aorta and in the left supraclavicular cavity (fig. 1c, d).
a, b Endoscopic findings (a) and CT scan (b) after 8 months. The primary lesion disappeared, and lymph node metastases diminished markedly. c, d CT (c) and FDG-PET (d) after 48 months. Swollen lymph nodes were not seen anymore.
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F2
After the start of treatment, the primary lesion disappeared and lymph node metastases also markedly decreased in size (fig. 2a, b). In December 2003, the patient was rated as showing complete response on the basis of findings from 2-deoxy-18F-fluoro-glucose positron emission tomography (FDG-PET) and CT (fig. 2c, d).
Time course of CEA and chemotherapy.
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F3
CEA normalized at the end of the 10th course of treatment (fig. 3).