Case report – pancreatic  cancer
T.Rohan
Department of Radiology and Nuclear Medicine University Hospital Brno and Faculty of Medicine
Masaryk University
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Male, 56 years old
•Emergency department
•Pain of  the epigastrium after meal 5 weeks ago,  than it stopped. One week ago wandering pain off
the whole abdomen. Visited general practitioner, who recommended him to visit hospital.  Today -
severe pain of the epigastrium, newly developer lubar pain and pain of the left hypogastrium.
•Clinical findings: peritoneal sigs not present, liveer and spleen not palpable, tapottment
negative, peristaltis audible
•Anamnesis: diabetes mellitus 1st type, former smoker
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•X-ray and ultrasound of the abdomen were indicated
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Abdominal ultrasound – request
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•Results of blood tests were not available at the time of ultrasound examination.
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Abdominal ultrasound – summary
•2 hypo-isoechoic liver tumors (image) – on the ground of weight loss (patient asked during
ultrasound examination) metastasis was considered, but benign etiology is also possible.  Because
of emergency examination contrast agent was not administered and therefore the etiology could not
be specified. Pancreas was not visible due to artefacts (gas) from bowels.
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Abdominal X-ray - summary
•No signs of pneumoperitoneum or bowel obstruction.
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UPRIGHT – no pneumoperitoneum
SUPINE – no dilation of bowel loops

Blood test
•Bi-celk. 5.7 umol/l, ALT 0.36 ukat/l, AST 0.31 ukat/l, GGT 0.76 ukat/l, ALP 1.21 ukat/l, AMS 0.63
ukat/l,
•Glukóza 13.3 mmol/l, CRP less than 1.0,
•Urea 3.3 mmol/l, Kreat. 70 umol/l
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•Clical signs + X-ray + Ultrasound of the abdomen + blood test does not indicate acute abdomen.
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Evaluation of weight loss and liver tumor
-Oncomarkers (elevation of CA19-9 4238 kU/l – suspected tumor of pancreatobiliary origin)
-Deterioration of blood tests during following 10 days: Bi-celk. 94.1 umol/l, ALT 11.33 ukat/l, AST
8.59 ukat/l, GGT 27.25 ukat/l, ALP 8.26 ukat/l
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•CT focused on pankreas and liver tumors was indicated.
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CT of the abdomen - summary
•Tumor of pancreatic head infiltrating the duodenum, in close contact with inferior vena cava.
Regional lymfadenopathy.
•Two liver tumors characterised like hemangiomas.
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Abdominal CT in arterial phase – tumor with  granular enhancement on the periphery – typical of
hemangioma
CT  with intravenous contrast is suitable method for diagnosis and staging of pancreatic cancer.
Intravenous contrast is necessary for characterisation of liver tumors on CT.
Abdominal CT in portal phase – voluminous gall bladder is one of thee typical signs of pancreatic
head tumor. Width of gallbladder is normally  up to 4 cm (in the image is 4,5 cm).
Abdominal CT in arterial CT (right) and portal phase (left) – hypodense tumor of pancreatic head
bulging into the duodenum (in duodenum is positive perorally administered contrast). Portal vein
(asterixis) and superior mesenteric artery  (circle) without signs of infiltration. Borderline
width of ductus hepatocholedochus (width 7 mm, normally up to 7 mm).Regional lymfadenopathy
(triangle). Bilateral parapelvic cysts of the kidneys.

Follow-up
•Presentation on tumor board.
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•Tumor board recommends surgical revision, becasue there were no signs of distant metastasis and
infiltration of portal vein and superior mesenteric artery on CT.
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•But during surgery the tumor was found to be curatively unresectable, sample for histopathology
was taken (low grade adenocarcinoma) and paliative bypass surgery was performed (Roux en Y with
choledochojejunal anastomosis, gastroenteroanastomosis and enteroenteroanastomosis).
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•Paliative chemotherapy was indicated.
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Summary
•Pancreas is not always visible on ultrasound (visibility is limited in obese patiens and due to
gas in stomach and transverse colon).
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•If pancreatic tumor is suspected, CT with intravenous contrast is indicated.
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•CT is suitable method for staging of pancreatic cancer.
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•Intravenous contrast is necessary for characterisation of liver tumors on CT.
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