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Special Feature
August 2010

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Hepatobiliary Unit, Department of Surgery, Catholic University of the Sacred Heart, A. Gemelli Medical School, Rome, Italy.

Arch Surg. 2010;145(8):793. doi:10.1001/archsurg.2010.143-a

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).

Figure 1
Computed tomographic scan. The white arrow indicates the mass; the black arrow indicates the stent.

Computed tomographic scan. The white arrow indicates the mass; the black arrow indicates the stent.

Figure 2
Surgical specimen. Histologic examination (inset) at the bottom (hematoxylin-eosin, original magnification ×400).

Surgical specimen. Histologic examination (inset) at the bottom (hematoxylin-eosin, original magnification ×400).

What Is the Diagnosis?

A. Ductal adenocarcinoma of the pancreas

B. Papillary cystic neoplasm of the pancreas

C. Metastasis from leiomyosarcoma

D. Neuroendocrine pancreatic tumor

Answer

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