PMC8045707_01
The first abdominal MRI. Both MR T1 (A) and T2 weighted image (B) showed the atrophy of the pancreas and inhomogeneous signal change in the body and tail of the pancreas. Diffusion weighted image didn't show the apparent tumor mass-related signal change (C). Gadolinium-enhanced T1 weighted images including early arterial phase (D), late arterial phase (E) and portal phase images (F), depicted multiple irregular hypointense signals without demonstrating a typical tumor imaging characteristics, which was regarded as an indeterminate lesion in the pancreas. A recommendation of imaging follow-up was made for the patient.
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The patient underwent MRI, which revealed abnormal signal changes in the body of pancreas, the atrophy of the pancreatic tail, dilation of distal pancreatic duct, and less enhancement than the pancreatic parenchyma ( Figure 1 ).
The second imaging. CT without contrast administration show the significantly enlarged tumor mass with heterogeneous components of central cystic low attenuation, peripheral solid isointensity and small patchy calcification (A, arrow). Contrast-enhanced CT shows the tumor mass with intermediate enhancement of the peripheral component and the non-enhanced cyst-like central area (B, arrow). MR T2 (C) and T2 weighted images (D) show heterogeneous hyper-signal intensity and hypo-signal intensity in the central area of the tumor (arrow). DWI shows the apparent diffusion restriction-induced heterogeneous hypersignal intensity (E, arrow). Contrast-enhanced MR weighted images of arterial (F), portal (G) and equilibrium phase (H) show the tumor mass with intermediate enhancement of the peripheral component, the non-enhanced cyst-like central area (arrows).
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Mild enhancement of the solid components and non-enhancement of the central necrosis were also present ( Figures 2A, B ). MRI showed inhomogeneous hyperintensity on T2 weighted images, restricted diffusion on diffusion-weighted images, and mild inhomogeneous enhancement of the solid components on the gadolinium-enhanced T1 weighted images ( Figures 2C-H ).
Pathological examination. Histology with H&E staining of the excised pancreatic tumor mass shows large pleomorphic, spindle-shaped cells, fibrosis, which indicate a stromal malignancy (A). Another slide of the tumor shows schistosome in the tumor tissue (B, arrow).
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The diagnosis of PL was confirmed by H&E morphology and immunohistochemical staining ( Figure 3A ). Interestingly, few dead Schistosoma eggs were found in the tumor tissues ( Figure 3B ), and a large number of eosinophils surrounded the Schistosoma eggs.
Follow-up images after surgery. Lung CT shows multiple nodules in the lung and thoracic effusion, which indicate the lung and possible pleural metastasis (A, B, arrow). MR T1 weighted images show a well-demarcated, heterogeneous hypointense signal tumor in the right lobe of the liver with patchy hypersignal intensities in the central of the tumor (C, arrow). MR weighted images show the tumor mass with heterogeneous hypersignal intensities (D, arrow). Contrast-enhanced MR weighted images of arterial (E), portal phase (F) show the tumor mass with intermediate enhancement of the peripheral component, the non-enhanced hypointense signal central area (arrows).
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Twenty months after surgery the patient developed liver and lung metastasis ( Figure 4 ), and she died three months later.