case_images: PMC6370588_01
case_images: Preoperative computed tomography (CT).. Inhomogeneous hypodense ill-defined focal lesion of the head of the pancreas (white arrows) with a dilated intra- and extrahepatic bile duct system due to a mass effect (black arrows) (A transverse image, porto-venous phase; B coronal image, porto-venous phase). Note the healthy adjacent parenchyma of the pancreas (white asterisks) and lack of signs of local irresectability.
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case_images: Using contrast-enhanced multi-phase computed tomography (CT), a tumor in the head of the pancreas associated with a distal biliary obstruction was diagnosed suspicious for pancreatic cancer (Fig. 1).
case_images: Percutaneous transhepatic cholangiodrainage (PTCD).. Conventional percutaneous cholangiogram with opacification of a dilated intra- and extrahepatic bile duct system (black arrow) with signs of a malignant stenosis at the level of the head of the pancreas (white arrows) (A). Control cholangiogram after positioning of a 8 F PTCD for combined external/internal drainage (black arrow: configuration of the pigtail of the PTCD in the duodenum; white arrows: bridging of the malignant obstruction via the 8 F PTCD) (B).
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case_images: Postoperatively, due to persistent jaundice, the patient received percutaneous transhepatic bile duct drainage (PTCD) for combined external/internal drainage which was changed on October 6, 2017 to a self-expanding metal stent (SEMS) for permanent recanalization of the bile duct (Fig. 2).
case_images: Computed tomography following PTCD.. Control CT with adequate positioning of the PTCD (black asterisks) and relief of the bile duct system, and constant ill-defined tumor in the head of the pancreas (white arrows) (A transverse image, arterial phase; B coronal image, porto-venous phase).
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case_images: The patient again underwent staging, which revealed no signs of liver or lung metastasis (Fig. 3).
case_images: Histopathology (hematoxylin-eosin staining).. (A) Histopathology of the pancreatic head following Whipple s procedure reveals an intraductal tubulopapillary neoplasm (ITPN) with typical papillary growth and beginning invasion (arrow). In contrast to IPMN no overt mucin production was observed. (Original magnification, x 25).. (B) Intraductal tubulopapillary neoplasm (ITPN) with associated invasive ductal adenocarcinoma (arrow). (Original magnification, x 25).
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case_images: Final histopathology of the surgical specimen surprisingly revealed a pT3, pN0 (0/12), R0, G2 ductal adenocarcinoma arising in the background of an ITPN (Fig. 4).
case_images: Hematoxylin-eosin staining and immunohistochemistry with Cytokeratin 7.. (A) Hematoxylin-eosin staining in a higher magnification reveals atypical tumors cells with high-grade dysplasia and a high proliferation rate (arrow). (Original magnification, x 100).. (B) Immunohistochemical staining of the tumor shows ubiquitously positive results for Cytokeratin 7 (CK7) as marked in brown color indicating a highly malignant behavior of the tumor. (Original magnification, x 25).
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case_images: Synaptophysin, and Trypsin (Fig. 5). Since the tumor did not show expression of these markers, a neuroendocrine tumor and an acinus cell differentiation were excluded.