RT Journal
A1 Clemente G, Giordano M, De Rose AM, Nuzzo G
T1 IMage of the month—quiz case
JF Archives of Surgery
JO Archives of Surgery
YR 2010
FD August 1
VO 145
IS 8
SP 793
OP 793
DO 10.1001/archsurg.2010.143-a
UL http://dx.doi.org/10.1001/archsurg.2010.143-a
AB 
A 57-year-old woman presented with cholic pain and jaundice. Twelve years before, she had a hysterectomy with the unexpected histological finding of leiomyosarcoma, and in a “second-look” procedure, a bilateral salpingo-oophorectomy was done without any evidence of residual tumor. Ultrasonography showed small stones in the gallbladder and a dilated common bile duct; ultrasonographic assessment of the pancreas was difficult because of interposed gas-containing loops. Diagnosis of choledocholithiasis with migrating stones from the gallbladder to the common bile duct was made and a sequential treatment with endoscopic retrograde cholangiopancreatography plus endoscopic sphincterotomy followed by laparoscopic cholecystectomy was planned. Surprisingly, at the endoscopic retrograde cholangiopancreatography, a neoplastic stricture of the common bile duct was found and a transtumoral endoprosthesis was inserted. A computed tomographic scan showed, in the portal phase, a round and well-defined mass with inhomogeneous enhancement at the level of the head of the pancreas with dilatation of the main pancreatic duct (Figure 1; white arrow indicates the mass; black arrow indicates the stent). Endoscopic ultrasonography confirmed the mass but cytologic examination of the fine-needle aspiration biopsy specimen was unremarkable. The patient underwent a Whipple procedure to remove her cephalopancreatic mass (Figure 2; histologic examination at the bottom).