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case_images: Computed tomography (CT) scan showing pancreatic head tumor (red arrow heads) causing dilatation of biliary and pancreatic ducts. A: axial view; B: coronal view.
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case_images: An abdominal computed tomography (CT) scan revealed a hypo-vascular mass with 16-mm in diameter located in the head of the pancreas causing dilatation of biliary and pancreatic ducts (Fig. 1A, B).
case_images: Computed tomography (CT) scan showing swellings of distant lymph nodes (red arrow heads). A: para-aortic lymph nodes (red arrow heads); B: left supraclavicular node (red arrow heads).
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case_images: The swelling of multiple para-aortic lymph nodes and a left supraclavicular lymph node (Virchow's node) was also observed (Fig. 2A, B).
case_images: Histopathological findings of biopsy specimen consistent with well differentiated adenocarcinoma (hematoxylin-eosin staining). A: low magnification; B: high magnification.
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case_images: The result of biopsy was concordant with well differentiated tubular adenocarcinoma (Fig. 3A, B).
case_images: Transition graph of serum carbohydrate antigen 19-9 (CA19-9) level and the treatment progress.
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case_images: Serum CA19-9 level was sharply decreased to 7543.2 U/mL (almost 90% reduction) (Fig. 4). A CT scan revealed that shrunken lymph nodes had remained stable, and serum CA19-9 level became almost normal (38.5 U/mL) (Fig. 4).
case_images: Computed tomography (CT) scan after FOLFIRINOX (combination of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) treatment showing only tiny appearances of distant lymph nodes. A: para-aortic lymph nodes (red arrow heads); B: left supraclavicular lymph node (a red arrow head); C: primary lesion (red arrow heads).
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case_images: As to primary lesion, significant uptake was not observed in PET-CT although hypo-vascular mass remained left side of the metallic stent (Fig. 5C, 6C).
case_images: Positron emission tomography (PET)-CT scan just before conversion surgery showing no distant metastases. A: para-aortic lymph nodes; B: left supraclavicular lymph node; C: primary lesion.
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case_images: A positron emission tomography (PET)-CT scan also showed no abnormal uptake in distant lymph nodes (Fig. 6A, B). As to primary lesion, significant uptake was not observed in PET-CT although hypo-vascular mass remained left side of the metallic stent (Fig. 5C, 6C).
case_images: Surgical specimen of subtotal stomach preserving pancreaticoduodenectomy (A) and an intraoperative picture after dissection of para-aortic lymph nodes (B).
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case_images: Given these results, and after discussion at multidisciplinary cancer conference, the patient underwent subtotal stomach preserving pancreaticoduodenectomy with dissection of para-aortic lymph nodes 8 months after the initiation of chemotherapy (Fig. 7A, B).
case_images: Histopathological findings of surgical specimen showing scattered foci of grade IB pancreatic intraepithelial neoplasia (hematoxylin-eosin staining, x100) (a white arrow).
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case_images: Histopathological examination of the surgical specimen showed no evidence of residual adenocarcinoma in neither pancreas head nor 54 dissected lymph nodes including para-aortic nodes, although scattered foci of grade IB pancreatic intraepithelial neoplasia were observed (Fig. 8).