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RADIOLOGY: PANCREAS: Case# 84: EARLY PANCREATIC CANCER. Current Exam: 80 year old black female with prior fever, abdominal pain, nausea, vomiting and weight loss presents with obstructive jaundice. Previous Exam: 80 year old woman with a history of vague abdominal discomfort at night. Current Exam: Comparisons are made with previous CT. The gallbladder is markedly enlarged compared to a previous exam without cholelithiasis or gallbladder wall thickening. There is mild intrahepatic duct dilatation but marked dilatation of the common bile duct to a diameter of 2.0 cm. The pancreatic duct is only slightly dilated. A focal mass is present within the pancreatic head measuring 3.3 cm x 3.8 cm. The mass is notably larger than the pancreatic body and has enlarged since previous scan. There is no associated adenopathy. Past Exam:There is mild diffuse fatty infiltration of the liver. No other focal hepatic or splenic lesions are seen. The pancreas, adrenals, kidneys, ureters and bladder are unremarkable. No free intraperitoneal fluid or adenopathy is seen. This almost uniformly fatal cancer is the 4th most common malignant tumor accounting for 5% of cancer deaths in the United States. Symptoms are usually nonspecific and insidious such that the cancer is advanced by the time of diagnosis. Most cancers occur in the head of the pancreas and are usually adenocarcinomas arising from ductal cells. The sensitivity of CT scan in diagnosing pancreatic carcinoma is approximately 95% whereas that of ultrasound is less than 80% for cancer of the head and 40% for the tail. The primary finding on CT is a focal mass;however, if no mass is present, other findings may suggest neoplasm. First, the pancreas may become more heterogeneous in density with age. Thus, a focal region of homogeneous soft tissue density might raise suspicion of a carcinoma. The presence of both a dilated common bile duct and a dilated main pancreatic duct in the absence of calculus suggests ampullary or pancreatic head neoplasm, but this may also be seen in benign disease. The finding of a dilated main pancreatic duct in the body or tail but not in the head or neck suggests neoplasm, and finally, the finding of rounded convex borders of both anterior and posterior surfaces of the uncinate process raises suspicion for carcinoma. Ten to fifteen percent of patients will have potentially resectable tumors, and they may be distinguished by CT findings. Signs of potential resectability include an isolated pancreatic mass with or without dilatation of the bile and pancreatic ducts and combined bile-pancreatic duct dilatation without an identifiable pancreatic mass. Extension of the tumor beyond the margins of the pancreas, involvement of adjacent organs or the SMA, liver metastases, ascites, and regional adenopathy are signs of unresectability. Unfortunately, most of those who undergo resection eventually die of pancreatic cancer.

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Peter Anderson
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