case_images: PMC11266157_01
case_images: Imaging Features of DPC in case 1. (A) Abdominal CT scan showing a nodule (3.7x2.2 cm). (B) PET/CT images demonstrating a single focus in the upper abdomen (red circle). (C) ERCP revealing an elevated lesion measuring 3.7 mm in diameter at the duodenal papilla of Vater. (D) H&E staining indicating poorly-differentiated adenocarcinoma of DPC (magnification, x20). (E-H) IHC showing tumors positive for CK7, CK19, and MUC1, and negative for MUC2. (I) Apoptosis index. Ki-67 positive rate was about 50%.
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case_images: Additionally, a solid mass measuring 3.7x2.2x1.7cm was detected at the ampulla of Vater ( Figure 1A ). 18F-FDG PET/CT scan exhibited an intense FDG uptake in the duodenal mass, suggestive of malignancy ( Figure 1B ). Subsequent endoscopic retrograde cholangiopancreatography (ERCP) revealed a large tumor at the papilla of Vater, from which multiple biopsies were taken ( Figure 1C ). Histological examination showed abundant malignant epithelial cells characterized by cuboidal cells with rounded nuclei arranged in a monolayer, accompanied by infiltrative interstitial inflammatory cells ( Figure 1D ). Immunohistochemistry (IHC) staining was positive for CK7, CK19, MUC1, and Ki67 (40%), and negative for MUC2 ( Figures 1E-I ).
case_images: The examination results of Case 1 after 125I implantation. (A) Placement of 125I seed strands on the tumor surface. (B) Three months after 125I seed implantation, enhanced CT indicated the treatment response was PR. (C) Three months after brachytherapy, duodenoscope revealing disappearance of the lesions, with no duodenal obstruction. (D) Eight months after 125I seed implantation, tumor disappeared (the red circle). (E) Ten months after 125I seed implantation, no recurrence (the arrow indicates the duodenal papilla). (F) The images of duodenography and cholangiography.
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case_images: Subsequently, the patient underwent percutaneous transhepatic cholangiodrainage (PTCD) on October 21, 2022, followed by 125I seed implantation ( Figure 2A ). According to the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1), a partial response (PR) was observed by January 2023, with a 59.5% reduction in the maximum diameter (decreased from 3.7 cm to 1.5 cm) ( Figure 2B ). By June 2023, a complete response (CR) was achieved, with no tumor identified via duodenoscopy and CT imaging ( Figures 2C, D ). The latest follow-up CT scans in August 2023 confirmed no significant changes at the lesion sites ( Figures 2E, F ).
case_images: PMC11266157_02
case_images: Imaging Features of DPC in case 2. (A) MRCP demonstrating a 2.0 cmx1.5 cm mass in the duodenal papilla. (B, C) ERCP examination indicating elevated lesion and obstruction of the common bile duct (arrowhead). (D) H&E staining of mass tissues (magnification, x20). (E-H) IHC indicating tumors positive for CDX2, CK7, and CK19, and negative for Cerb-B2 (magnification, x20). (I) Apoptosis index. Ki-67 positive rate was about 40%.
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case_images: Figure 3A ). Furthermore, dilatations of the bile ducts and pancreatic ducts were observed. Subsequent ERCP revealed an obstruction at the terminal of the common bile duct ( Figures 3B, C ). Histopathological examination by hematoxylin and eosin (H&E) staining presented a cribriform architecture and pseudostratification, which was consistent with a diagnosis of moderately differentiated adenocarcinoma of DPC ( Figure 3D ). Immunohistochemical staining showed positivity for CDX2, CK7, and CK19 (focal), with Cerb-B2 negativity ( Figures 3E-H ). A mitotic index was noted with a Ki67-positive rate of 60% ( Figure 3I ).
case_images: (A) Patient in case 2 undergoing PTBD and biliary 125I seed implantation. (B) Duodenoscope revealing reduction of the lesions. (C, D) Biliary stricture (arrowhead) and metal bile duct stent implantation.
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case_images: Percutaneous transhepatic biliary drainage (PTBD) and biliary linear 125I seed implantation were performed in July 2022 ( Figure 4A ), alongside anti-infection therapy, nutritional support, and pain management. A significant reduction in the duodenal papilla mass to 1.0 cm x 0.5 cm (with 50% reduction) was observed two months post-treatment ( Figure 4B ). Given the biliary stricture and to avoid the need for a prolonged intubation of drainage tube, procedures were successfully completed, including the extraction of the plastic bile duct, pancreatic duct stents, the biliary drainage tube and biliary linear 125I seeds, followed by the placement of a metal bile duct stent ( Figures 4C, D ).
case_images: Timelines of major events in both cases.
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case_images: Regrettably, the patient succumbed to the Covid-19 in January 2023 ( Figure 5 ).