Pancreatic ductal adenocarcinoma (MRCP)

Case contributed by Bruno Di Muzio
Diagnosis certain


Painless obstructive jaundice with biliary dilatation to the ampulla.

Patient Data

Age: 70 years
Gender: Male

There is diffuse intra- and extrahepatic ductal dilatation. The common bile duct measures up to 19 mm in AP diameter. The gallbladder is distended. The main pancreatic duct is dilated, measuring up to 8 mm.

There is an abrupt tapering of the common bile duct and hepatic ducts at the pancreatic head. There is the impression of a slightly T2 hyperintense mass in the pancreatic head/uncinate process, measuring approximately 2.4 x 3.4 x 2.7 cm. Enlarged lymph node with a short-axis diameter of 14 mm is identified in the celiac axis, superior to the pancreatic neck. This demonstrates mildly increased diffusion restriction. The pancreatic body and tail are mildly atrophic.

There are no filling defects anywhere within the biliary tree to suggest calculi. No calculi or sludge in the gallbladder.

No focal liver lesion. Normal appearance of the spleen.

Loss of corticomedullary differentiation in both kidneys. Small T2 hyperintense lesions in the right kidney are in keeping with cysts. Normal adrenal glands.

Conclusion: Pancreatic head mass/uncinate process is very suspicious for pancreatic malignancy. Associated biliary and pancreatic ductal obstruction with an enlarged lymph node. No evidence of biliary calculi.

Macroscopy: endoscopic ultrasound-guided FNA of pancreatic head mass—needle cores received in formalin.

Microscopy: normal duodenal epithelium and fragments of fibrous connective tissue within which there are variably sized glands infiltrating and lined by moderately pleomorphic epithelium. Features are those of adenocarcinoma.

Conclusion: FNA of the pancreas head is mass-malignant.

Case Discussion

Case showing the double duct sign on MRCP due to a pancreatic head mass. Further, EUS and FNA confirmed pancreatic adenocarcinoma. CT chest and pancreas were then performed for staging completion.

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