Gastroenterology image challenge: A 64-year-old woman with a history of developed painful cutaneous erythema and nodules on her lower limbs for one month was referred to our hospital for examination. Physical examination showed multiple indurative erythema in conjunction with painful red-brown multiple nodules up to 4 cm in diameter on her lower limbs (figure A). There was no erosion or ulceration. She had no family history of pancreatic diseases and had not been drinking alcohol. She had experienced neither abdominal symptoms nor abnormal physical signs, such as fatigue, appetite loss or body weight loss.
Subsequent blood tests showed elevated liver enzyme levels (aspartate transaminase, 51.8 U/L; alanine transaminase, 43.6 U/L; alkaline phosphatase, 260 U/L) and an elevated tumor marker (carbohydrate antigen 12-5, 158.5 U/mL). Abnormal laboratory findings showed increased levels of white blood cells (12.89 × 109/L) and erythrocyte sedimentation rate (110 mm/h), and decreased levels of red blood cells (3.07 × 1012/L), hemoglobin (89 g/L), and albumin (27 g/L).
Magnetic resonance imaging revealed a solitary mass with a 1.9-cm diameter in the pancreas tail and multiple space-occupying lesions in the liver, the largest cystic mass of which was up to 8.5-cm diameter with a large necrotic area in the center (figure B).
What is the diagnosis?
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