A 64-year-old male with a history of insulin-dependent diabetes mellitus, dyslipidemia and recurrent renal colic.
She reported diarrhea with episodes of steatorrhea, constitutional syndrome and epigastric pain of two months duration.
The patient was admitted to the emergency department with progressive jaundice, choluria and acholia.
Physical examination revealed good general condition, malaise, normohydration and cutaneous-mucosal irritation.
Abdominal examination revealed the gallbladder to be obstructed and the rest of the abdomen was anodyne.
Analytically, he presented a hyperbilirubinemia of 17 mg/dl, with an increase of AAFC (2522 U/l) and γGT (107 U/l).
No leukocytosis.
Viral hepatitis markers were negative and there was an increase in CEA (7.6 ng/dl).
AFP and CA19.9 were normal.
Ultrasound showed minimal dilation of the intrahepatic bile duct and slight dilation of the bile duct; the gallbladder was hydropic and without stones.
A round, hypoechoic mass was observed in the head of the pancreas of approximately 2 cm, which was not confirmed in the CT, which, as additional information, described dilation of the duct of Wirsung.
Magnetic resonance cholangiography showed similar findings with clinical suspicion of ampuloma that was not evident on gastroscopy, which was strictly normal.
With the diagnosis of obstructive jaundice gastrectomy of probable malign origin, she was operated on one week after admission, finding a mass in the head of pancreas of neoplasic aspect, so a pancreatoduodenum was performed.
In the anatomopathological study the surgical specimen showed two areas of tumor aspect, clearly differentiated.
One of 1 cm and well-defined limits in the duodenal wall, and another of undefined edges of 3 cm in the pancreatic head.
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On microscopic examination, the duodenal tumor was composed of cords of polyhedral and uniform cells located in the muscular fascicles of the wall.
They showed nuclei with low degree of atypicality and very low mitotic activity.
Pancreatic tumor was formed by glandular structures located above the walls of the duodenum which were covered by columnar cells with very atypical nuclei and high mitotic index.
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Once the diagnosis was oriented.
Immunohistochemical techniques were applied to confirm the different nature of both tumors.
The resulting immunophenotype clearly differentiated both tumors, since the duodenal tumor was negative for CEA and positive for chromogranin, STH and glucagon and pancreatic adenocarcinoma was only positive for CEA.
After the immediate postoperative period in the ICU, the patient was discharged home after 19 days of intervention and went to the surgery ward.
She was given an adjuvant chemotherapy regimen based on gemcitabine 1 g/m2, in four cycles, one of seven weeks and three of three weeks intercaling a rest.
He recovered well during the first months but later he developed persistent right hypochondrium pain, nausea and vomiting.
Since the radiological examinations are anodyne, the patient was reoperated nine months after the first intervention, confirming recurrence, which was unresectable.
The patient suffered a progressive deterioration of the general condition and died 14 months after the first intervention.
