Presentation
Fever for the past 3 weeks, weight loss for the past several months. Long-standing back pain.
Patient Data
Mass at head of pancreas measuring 4.1 x 6.8 x 6.2 (TRV x AP x CC) cm, showing extensive necrosis and peripheral punctate calcifications. The mass occludes the portal confluence and invades the portal vein (PV) and superior mesenteric vein (SMV), with resultant cavernous transformation, as well as left gastric and esophageal varices. The pancreatic mass also surrounds the common hepatic artery (CHA).
Numerous tiny cysts scattered throughout the pancreas, not associated with the main pancreatic duct (MPD); largest is in body of pancreas and measures 11 mm in diameter.
Cysts scattered in both hepatic lobes; largest is in segment 8 and measures 4.2 cm across.
Two small exophytic cystic lesions with calcified walls in medial border of hepatic segment 2.
Diverticula in descending colon and sigmoid colon.
Urinary bladder with numerous small diverticula. Large stone in urinary bladder.
Evidence of TURP.
Moderate-sized right inguinal hernia containing fat and small amount of fluid. Small left inguinal hernia containing fat.
Retroaortic left renal vein.
Follow-up CT, 3.5 months later:
The pancreatic mass has grown to ~8 x 8 x 8 cm, not including the tumor thrombus, which has extended into both portal vein branches.
Virtually all the pancreatic cysts have grown in size.
New findings:
- internal biliary stent inserted due to common bile duct (CBD) being compressed by the mass; distended gallbladder
- innumerable hypodense hepatic metastases
- retroperitoneal para-aortic metastases
- ascites, large amount
Case Discussion
The patient had undergone a CT spine (not shown; cannot be accessed) for long-standing back pain, where a pancreatic mass was incidentally discovered. CT pancreas clearly showed the mass to occlude the portal confluence and envelop the CHA, rendering it inoperable. A biopsy from the mass was obtained by endoscopic ultrasound (EUS).
Histopathology report:
Pancreatic undifferentiated carcinoma (see comment).
Comment: Cellular neoplasm with highly atypical cells, consistent with
undifferentiated carcinoma of the pancreas. There are cells resembling
osteoclast-like giant cells making undifferentiated carcinoma with
osteoclast-like giant cells in the differential.
A follow-up CT several months later showed hepatic and retroperitoneal metastases, as well as ascites. An internal biliary stent had been inserted after the CBD had been occluded due to compression by the mass.