Duodenal Carcinoma with Biliary Obstruction

Prior Duodenal Surgery and Jaundice • Xray of the Week 2016 • Week #32

This 54 year old female had prior duodenal surgery and presented with jaundice. What is the diagnosis and treatment?

Fig. 1 CT scan. Mass in the porta hepatis region, surgical staples in the duodenum, and biliary dilatation.

Bottom right: Severe biliary dilatation also seen on the Percutaneous Transhepatic Cholangiogram (PTC). Note that no contrast enters the duodenum, despite distention with contrast, indicating high grade obstruction.

Fig 2. Left: MRI Coronal FSE T2WI demonstrates a mass in the porta hepatis region and biliary dilatation.

Right: Severe biliary dilatation seen on the 3D MRCP image.

Video showing how I placed a stent in the common bile duct (CBD) and relieved the biliary obstruction.

Duodenal Carcinoma is a rare gastrointestinal malignancy, comprising 0.3% of all GI tract cancers. (1,2) Almost always adenocarcinoma, the neoplasm is the most common malignant tumor of the duodenum. Symptoms are nonspecific and include weight loss, abdominal pain, and later in the process jaundice and vomiting due to gastric outlet obstruction. (1,2) As in this case CT shows a mass or asymmetric thickening of the duodenum, with invasion of fat planes, pancreatic and biliary duct dilatation, and vascular encasement. (1)

The overall 5 year survival in one study of 89 patients was 25% (4) with improved outcome following radical surgery. If diagnosed late as in this case, there is a very poor prognosis. (4)

References:

1. Jayaraman MV, Mayo-Smith WW, Movson JS et-al. CT of the duodenum: an overlooked segment gets its due. Radiographics. 2001;21 Spec No (suppl 1)

2. Markogiannakis H, Theodorou D, Toutouzas KG et-al. Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature. Cases J. 2008;1 (1): 98.

3. Imaging Features of Benign and Malignant Ampullary and Periampullary Lesions. RadioGraphics 2014; 34:624–641

4. Santoro E, Sacchi M, Scutari F, Carboni F, Graziano F: Primary adenocarcinoma of the duodenum: treatment and survival in 89 patients. Hepatogastroenterology. 1997, 44 (16): 1157-1163.

Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field.

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