Presentation
Epigastric pain.
Patient Data
The liver, gallbladder, spleen, aorta, IVC, right adrenal glands, and kidneys are normal. Small simple cysts incidentally noted at the upper pole of the right kidney.
No intra-hepatic biliary dilatation. The common duct is dilated up to 14 mm in diameter but does taper down to 7 mm at the ampulla.
There is a 15 x 18 x35 mm low-density mass seen within the left adrenal gland which has not changed in appearance compared with the outside scan from 2 years ago - attenuation inferior to 10HU. Within the body of the pancreas, there is low-density mass lesion seen measuring 24 x 25 x 21 mm consistent with the history of known pancreatic carcinoma. Adjacent macrocalcifications seen within the pancreas.
There is abnormal soft tissue material seen around the proximal celiac axis and adjacent to the proximal SMA suspicious for metastatic disease. This appears separate from the primary pancreatic mass. No other evidence of metastatic deposits within the abdomen. No other lymphadenopathy in the abdomen pelvis or retroperitoneum.
The bowel has a normal appearance. Normal appendix.
No ascites.
No suspicious bone lesions.
Comment:
Low-density mass within the body of the pancreas consistent with a history of primary pancreatic malignancy with metastatic disease suspected around the celiac axis and adjacent to the proximal SMA.
Stable mass within the left adrenal gland.
Magnified views of the body of the pancreas tumor and vascular involvement: tumor encasement of the splenic artery, celiac trunk, common hepatic artery, and origin of the left gastric artery. Also, the tumor abut in involves in less than 180 degrees te SMA.
Case Discussion
This case illustrates an unresectable pancreatic ductal adenocarcinoma due to complete encasement of the celiac trunk and proximal portions of its branches (T4 disease)
Macroscopy: Endoscopic ultrasound-guided FNA of pancreatic body mass - 2 passes: 1 air-dried and 1 alcohol-fixed smear prepared along with a cell block. Cytologist in attendance.
Microscopy: The smears show a population of atypical epithelial cells with moderately pleomorphic, enlarged nucei, irregular nuclear membranes, coarsened nuclear chromatin, conspicuous nucleoli and moderate amounts of vacuolated cytoplasm, arranged singly and in flat sheets within a background of macrophage and blood.
Immunohistochemistry, performed on cell block, shows the atypical cell population are immunoreactive with antibodies against CK7 and negative with antibodies against CK20, CDX2 and CD56.
Conclusion: Pancreatic body mass, endoscopic ultrasound-guided FNA: Malignant. Features consistent with adenocarcinoma.
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