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Image challenge: An unusual pancreatic mass with ductal disruption

Is the mass, found in a 44-year-old woman with no remarkable history, benign or malignant?
Image Challenge 09282021
Image Challenge 09282021

Gastroenterology image challenge: A 44-year-old woman with no remarkable history was referred for a dilatation of the main pancreatic duct (MPD) incidentally found on a computed tomography (CT) scan. She was asymptomatic and had no family history of pancreatic disease. Laboratory data were unremarkable, including findings for tumor markers (carcinoembryonic antigen, 0.7 ng/mL; carbohydrate antigen 19-9, 15 U/mL) and serum-IgG4 of 37 mg/dL.

A contrast-enhanced CT (CE-CT) scan showed an ill-defined lesion in the pancreatic body that was hypodense (figure A) in the late arterial phase and hyperdense in the equilibrium phase compared with the surrounding pancreatic parenchyma. Endoscopic ultrasonography (EUS) examination revealed a 13-mm hypoechoic mass in the pancreatic body (figure B). The MPD was measured up to 3 mm caudal to the lesion, but no MPD dilation or parenchymal atrophy were apparent in the pancreatic tail (figure C). Endoscopic retrograde pancreatography showed that the MPD was disrupted at the body with a tapered end (figure D). An EUS-guided fine-needle biopsy (EUS-FNB) obtained from the lesion revealed atrophy of the pancreatic acinus, fibrosis of the stroma and infiltration of lymphocytes, but no tumor cells or IgG4-positive plasma cells were found.

What is the diagnosis and strategy for treatment?

To find out the diagnosis, read the full case in Gastroenterology.

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