A 58-year-old man presented with weight loss, jaundice and abdominal pain. Laboratory parameters were compatible with obstructive jaundice. CA19-9 was elevated (214 UI/mL). MRI demonstrated a solid tumor at the pancreatic neck. The axial diameter of the tumor was 2.2 cm, encasing the porto-splenic-mesenteric confluence (>180°), with SMV compromise of 18 mm (longitudinal axis) and without compromise of CA and SMA (Figure A,B). There was no evidence of lymph node involvement or metastatic disease. An endoscopic ultrasound-guided fine needle aspiration biopsy was obtained. Pathology revealed a well-differentiated pancreatic adenocarcinoma. At the same time a biliary stent was placed. The patient received three cycles of chemotherapy (gemcitabine: 1,000 mg/m2 and cisplatin: 50 mg/m2) every two weeks. He also commenced radiotherapy (50.4 Gy in 30 fractions) and infusional 5-fluorouracil (200 mg/m2). The dose had to be reduced by 20% due to thrombocytopenia. At the end of treatment, CA19-9 dropped to 124 UI/mL. Follow-up MRI demonstrated further reduction in local disease, with no evidence of porto-mesenteric infiltration (Figure C,D). Based on his remarkable response the decision was made to explore the patient, so he underwent a Whipple procedure with curative intention.\nHistopathological analysis of the specimen demonstrated a 1.5 cm, moderately differentiated pancreatic adenocarcinoma with extensive signs of regression, with multiple microscopic infiltrative foci (Figure ). Surgical margins were free of disease.
A 72-year-old man presented with a history of abdominal pain, jaundice and weight loss. Laboratory results demonstrated a cholestatic pattern. CA19-9 was 37.8 UI/mL. Diagnostic studies revealed a 1.8 cm pancreatic mass, encasing the porto-splenic confluence (>180°) with attachment to the SMA (<180°) (Figure A,B). Unfortunately, it was not possible to perform a needle biopsy due to technical difficulties. However, images were analyzed by a group of expert radiologists and evaluated with a multidisciplinary team composed of oncologists, gastroenterologists and HPB surgeons, who agreed in the diagnosis of pancreatic cancer.\nA biliary stent was placed, and relief of jaundice was achieved. He then commenced chemotherapy with gemcitabine (1,000 gm/m2) in combination with cisplatin (50 mg/m2) every two weeks. The patient completed three cycles of chemotherapy. During chemotherapy, cross sectional imaging suggested partial tumor regression, with increased patency of PV (compromise <180°) and less compromise of SMA (<90°), with no evidence of metastatic disease. The patient was referred for consolidation radiotherapy, of which he had a total of 50.4 Gy in 30 fractions and infusional 5-fluorouracil (200 mg/m2). He developed no major adverse effects.\nFollow-up CT demonstrated reduction in local disease (Figure C,D). Eleven months after the initial diagnosis the patient underwent surgery with curative intent in the form of a Whipple procedure. He had an uneventful recovery period.\nThe whole pancreatic specimen was sent for pathological examination, processed in blocks of 3 to 4 mm thickness. Macroscopically, there was no evidence of tumor. Sixteen paraffin blocks, 18 slides and 19 sections were reviewed. Further immunohistochemistry failed to confirm a pancreatic carcinoma. These findings were considered as a complete pathological response (Figure ).