Case 3

A 60 year old male patient is send into the hospital by his primary physician due to jaundice. On questioning, his only symptom is a loss of appetite. Laboratory findings: Bilirubin 6 mg/dl, gGT 250 U/l, AP 300 U/l.

The CT scan reveals a mass in the pancreatic head with no indications of metastasis.

After placement of the endoscope past the duodenal papilla and slow retraction, three lymph nodes are found at the level of the uncinate process of the pancreas. 

Characteristics of pathological lymph nodes: hypoechoic, > 1cm, round appearance (vs. the normal oval appearance), peripheral or mixed vascularization ( vs. zentral/hilar vascularization), the hilar region no longer distinguishable.

Fun Fact:

if a lymph node has all the pathological characteristics mentioned above, the likelihood of it being malignant is 80%, BUT, only 15% of malignant lymph nodes actually have all characteristics. 

While slowing withdrawing the endoscope, a pancreatic mass can be visualized. Rotating the shaft of the endoscope (i.e. causing the endoscopic image to move from left --> right), allows us to inspect the common bile duct arising from the pancreatic mass and heading into the liver hilum.

Above is an alternate view of the pancreatic mass. This image neatly depicts the anatomical structure surrounding the tumor. The Tumor itself is approximately 4 x 4 cm. In close proximity a lymph node can be seen, sharing some of the previously mentioned pathological characteristics. The pancreatic duct it slightly dilated. 

#Wichtig - Studien haben gezeigt, dass Patienten mit Pankreaskopfkarzinomen die operativ-kurativ behandelt werden sollen, ein erhöhtes Risiko für eine haematogene Tumorzellstreuung haben bei vorangegangenen Manipulation z.B. ERCP . D.h. Ein Ikterus muss keine zwingende Indikation zur ERCP sein.

Fun Fact:

Studies have shown, that patients with pancreatic tumors that is eligible to an operation, have an elevated risk for hematological spreading of malignant tumor cells due to mechanical manipulation, for example prior ERCP. This means that patients suffering from jaundice/elevated bilirubin levels, don't necessarily require ERCP Intervention (exceptions include cholangitis). 

Video coming ...