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Special Feature
January 2013

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City. Dr Makipour is now in private practice.

JAMA Surg. 2013;148(1):101. doi:10.1001/jamasurgery.2013.412a

A 50-year-old previously healthy man presented to the emergency department with epigastric pain for the past 3 months. He reported a 13.6-kg weight loss during this period with no nausea, vomiting, or diarrhea. He reported pruritus and dark, brown urine. He was notably jaundiced on physical examination, and his total bilirubin level was 7.7 mg/dL (to convert to micromoles per liter, multiply by 17.104). Notable laboratory findings include a Westergren erythrocyte sedimentation rate greater than 100 mm/h and a total protein level of 9.0 g/dL (reference range, 6.1-7.7 g/dL; to convert to grams per liter, multiply by 10.0). His medical history was significant for a cholecystectomy, nephrolithiasis, hypertension, and hypercholesterolemia.

An abdominal computed tomographic scan performed in the emergency department showed a hyperenhancing, multilobulated soft-tissue mass involving most of the pancreas with local extension into the gastrocolic ligament and the lesser sac (Figure 1). Endoscopic retrograde cholangiopancreatography showed a localized stenosis of the lower one-third of the common bile duct. Fine-needle aspiration biopsy was performed (Figure 2).

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Figure 1. Computed tomographic scan of the abdomen and pelvis.

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Figure 2. Findings on fine-needle aspiration biopsy (hematoxylin-eosin, original magnification ×200).

What Is the Diagnosis?

A.  Pancreatic adenocarcinoma

B.  Neuroendocrine carcinoma

C.  Non-Hodgkin lymphoma

D.  Extramedullary plasmacytoma