Pancreatogram
Date: 4/6/00
History: obstructive jaundice
Comparison: none
Procedure: contrast was injected into the biliary tree by the gi service under fluoroscopic observations.
Findings:
1. There is narrowing with a smooth tapering in the distal common bile duct with proximal dilatation of the common bile duct, right and left common duct and intrahepatic biliary duct. There is also dilatation of the pancreatic duct, and the evidence of common bile duct dilatation and pancreatic duct is more suspicious for a malignancy as the cause of the obstruction. 

2. At the end of the exam, stent was placed in the common bile duct.

Ct abdomen w contrast
Date: 04/06/00
History: obstructive jaundice. Patient has elevated bilirubin of 28.0.
Comparison: none.
Procedure: the patient received dilute oral and 150cc of non-ionic intravenous contrast. 7mm helical images were obtained without complication.
Ct findings:
1. Diffuse intrahepatic biliary ductal dilatation is identified. The common bile duct is also dilated measuring approximately 1.3 cm in diameter. The common bile duct can be followed to the region just superior to the head of the pancreas, however, it is not well visualized from that point inferiorly. In addition the pancreatic duct is moderately dilated. No focal pancreatic mass is identified and the head of the pancreas is normal in appearance. The dilatation of the intrahepatic ducts and common bile duct raises the possibility of a holangiocarcinoma. No focal hepatic lesion is identified.
2. There is no ascites.
3. No abdominal lymphadenopathy is seen.
4. The kidney is enhanced symmetrically and there is no evidence of hydronephrosis. An approximately 3 cm right parapelvic cyst
is identified in the interpolar region of the right kidney. In addition a tiny too small to characterize area is identified in the posterior aspect of the upper pole of the right kidney.
5. The adrenal glands are unremarkable.
6. Sequela and prior cardiac surgery is identified. A hiatus hernia is present.
7. The spleen is normal in size and no focal splenic lesion is identified.
8. The lung bases demonstrate a linear plate of atelectasis in the left lung base.
.
***
Impression:
1. Dilated intrahepatic biliary ducts with a dilated common bile duct. No focal pancreatic lesion is identified. The findings raise the possibility of a cholangiocarcinoma. Please also see ct scan of pelvis report performed on the same day.
***

Ct pelvis w contrast
Date: 04/06/00
History: obstructive jaundice. Patient has elevated bilirubin of 28.0.
Comparison: no Comparison available.
Procedure: the patient received dilute oral and 150cc of non-ionic intravenous contrast. 7mm helical images were obtained without complication.
Ct findings:
1. There is no free fluid within the pelvis.
2. No suspicious pelvic mass is identified.
3. Multiple sigmoid diverticula are noted without evidence of diverticulitis.
Please also see ct scan of abdomen report performed on the same day.

Endoscopic Ultrasound

Endoscopic ultrasound showed 1.9 cm tumor in the head of the pancreas.

Bile duct brushing:

Accessioned: 04/07/00
Tissue source: bile duct brushing:
Final diagnosis:
Bile duct brushing: specimen adequacy: satisfactory for evaluation.
Examination for neoplastic cells: few atypical epithelial cells are present.

Accessioned: 04/18/00
Tissue source:
1: fs-1 pancreatic mass bx 2: gallbladder 3: pancreas, duodenum, common duct
final diagnosis:
pancreas; biopsy: (specimen #1) -infiltrating poorly differentiated adenocarcinoma
gallbladder; cholecystectomy: (specimen #2) -chronic cholecystitis
stomach, pancreas, duodenum, and common bile duct; whipple
Procedure: (specimen #3) -poorly differentiated adenocarcinoma of common bile duct, with mucinous and signet ring features, infiltrating into adjacent duodenal wall, pancreas and peripancreatic fat
-specimen posterior margin and pancreatic cut surgical margin positive for tumor
-duodenal , gastric and common bile duct margins negative for tumor
-perineural invasion present
-2/10 lymph nodes with tumor and extracapsular extension -t3, n2, mx
(see comment)
cancer staging summary for pancreatic ampullary carcinoma
location............................common bile duct
size................................2.0 cm
histologic type.....................adenocarcinoma,with mucin and signet
ring features
histologic grade....................poorly differentiated
direct extension
retroperitoneal
peripancreatic tissue.....yes
duodenal wall..................yes
duodenal mucosa................no
common bile duct...............yes
other organs...................no
lymphatic/vascular invasion.........not identified
perineural invasion.................present
surgical margins
cut surgical margin of pancreas positive
peripancreatic and common duct
soft tissue.................... Positive
duodenal.......................negative
gastric........................negative
common bile duct...............negative
closest margin distance......
Regional lymph nodes (metastasis/total)2/10
superior inferior posterior....n/a
peripancreatic.................0/1
bile duct......................2/4 with extranodal extension
gastric........................0/5
duodenal.......................n/a
celiac.........................n/a
other (name)
extranodal extension (any).....present(bile duct nodes)
non neoplastic
pancreas.......................with chronic inflammation
gastric........................unremarkable
duodenum.......................unremarkable
ancillary studies...................n/a
ptnm................................t2, n2, mx

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