Pancreatic head adenocarcinoma

Case contributed by Dr Pranav Sharma

Presentation

Painful obstructive jaundice. Nausea. Vomiting. 10kg weight loss.

Patient Data

Age: 80 year
Gender: Female

CT Abdomen

CT

Findings:

  • There is marked dilatation of intrahepatic bile ducts and the common hepatic duct with the common hepatic duct measuring up to 12mm in transverse diameter.
  • There is abrupt narrowing at the junction of common hepatic ducts and common bile duct with the distal bile duct being normal in caliber.
  • The gallbladder is contracted.
  • The spleen and pancreas are normal apart from some dilatation of the pancreatic duct throughout as well as extensive vascular calcification involving mesenteric vessels. .
  • No para-aortic lymphadenopathy.  

​Conclusion: 

  • Substantial dilatation of intra-hepatic bile ducts and common hepatic duct with high suspicion of mass involving the bile duct at the junction of the common hepatic duct and common bile duct. The findings are very suspicious for diagnosis of primary neoplastic lesion involving the bile duct at this site.
  • More distal to the mass lesion the common bile duct is decompressed.
  • The gallbladder is contracted.
  • Some dilatation of pancreatic duct throughout it's length.  
  • Surgical opinion would be indicated in view of the findings. Further investigation by MRCP would be indicated in order to more fully asses the bile ducts and to confirm or exclude the presence of mass lesion at the junction of the common hepatic duct and common bile duct (KLATSKIN tumor).   

MRCP

MRI


Findings:

  • Marked intra and extrahepatic biliary distension is identified associated with upstream pancreatic duct enlargement.
  • There is a mass in the pancreatic head with loss of T1 signal, restricted diffusion and late enhancement present surrounding the common hepatic duct. This is associated with extension back into the pancreatic neck with ill-defined appearances leading to occlusion of the main pancreatic duct and the appearances would support a lesion of at least 2.4 cm in size with likely localized invasion outside the pancreatic head and around the common hepatic duct in the porta.
  • There are prominent surrounding lymph nodes which are concerning for involvement and there is narrowing of the portal veins slightly probably less than 180 degrees.
  • The left hepatic artery appears to be arising from the left gastric as a variant.
  • The hepatic artery proper appears to be encased along with the origin of the right hepatic artery and encasement of the GDA.
  • The SMA is clear, SMV is likely involved at the attachment to form the portal vein.
  • Patchy edema through the liver consistent with biliary obstruction is identified with no features supportive of metastatic deposits slightly prominent peri celiac nodes superiorly, no retroperitoneal deposits.

Conclusion: 

  • Appearances are likely a locally invasive 2.5 cm pancreatic head primary adenocarcinoma with double duct obstruction.
  • There is involvement of the right hepatic artery, hepatic artery proper and GDA with the left hepatic artery appearing to be replaced arising from the left gastric.
  • SMV and portal vein contact less than 180 degrees.
  • Small lymph nodes around the porta caval window are possibly just reactive.
  • Ill-defined tissues about the pancreatic head suggest an may be peripancreatic invasion into the adjacent lesser omentum and fat.
  • At this stage it is likely that this mass is status unresectable.   

Case Discussion

80-year-old lady presented with obstructive jaundice. CT and MRI concerning for mass involving the pancreatic head. Patient underwent an endoscopic ultrasound with fine needle aspiration and biopsy of the lesion. 

Final histopathology: Moderately differentiated adenocarcinoma. 

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