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A 57-year-old woman presented with cholic pain and jaundice. Twelve years before, she had a hysterectomy with the unexpected histological finding of leiomyosarcoma, and in a “second-look” procedure, a bilateral salpingo-oophorectomy was done without any evidence of residual tumor. Ultrasonography showed small stones in the gallbladder and a dilated common bile duct; ultrasonographic assessment of the pancreas was difficult because of interposed gas-containing loops. Diagnosis of choledocholithiasis with migrating stones from the gallbladder to the common bile duct was made and a sequential treatment with endoscopic retrograde cholangiopancreatography plus endoscopic sphincterotomy followed by laparoscopic cholecystectomy was planned. Surprisingly, at the endoscopic retrograde cholangiopancreatography, a neoplastic stricture of the common bile duct was found and a transtumoral endoprosthesis was inserted. A computed tomographic scan showed, in the portal phase, a round and well-defined mass with inhomogeneous enhancement at the level of the head of the pancreas with dilatation of the main pancreatic duct (Figure 1; white arrow indicates the mass; black arrow indicates the stent). Endoscopic ultrasonography confirmed the mass but cytologic examination of the fine-needle aspiration biopsy specimen was unremarkable. The patient underwent a Whipple procedure to remove her cephalopancreatic mass (Figure 2; histologic examination at the bottom).
Computed tomographic scan. The white arrow indicates the mass; the black arrow indicates the stent.
Surgical specimen. Histologic examination (inset) at the bottom (hematoxylin-eosin, original magnification ×400).
A. Ductal adenocarcinoma of the pancreas
B. Papillary cystic neoplasm of the pancreas
C. Metastasis from leiomyosarcoma
D. Neuroendocrine pancreatic tumor
Clemente G, Giordano M, De Rose AM, Nuzzo G. Image of the Month—Quiz Case. Arch Surg. 2010;145(8):793. doi:10.1001/archsurg.2010.143-a