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In brief, the following are some interesting and functional clinical cases to comprehend ultrasound diagnostics.

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  • Dott. Giorgio Bolognini
  • Clinical Cases
  • Jun 2025

CASE 20 - PANCREATIC ADENOCARCINOMA

Pancreatic tumor

A 95-year-old nulliparous woman in complete physical and mental health, who underwent appendectomy at a young age, has been visiting my office on the recommendation of a gastroenterologist for general gastrointestinal complaints (alternating diarrheal and constipation and epigastric abdominal pain) for approximately 3 months. She has not shown any weight loss, nor has she had any recent dysphagia or anorexia. Her blood tests are perfect except for a slight increase in her erythrocyte sedimentation rate (67). I am performing ultrasound with a convex probe and a linear probe given the patient's low BMI.
The examination, which began with a transverse scan of the epigastrium, immediately revealed a dramatic picture: "Presence of solid, frankly heteroplastic formations between the gastric antrum and the pancreatic body, initially compatible with developing lymph nodes; the largest, measuring approximately 38 x 31 mm, causes compression of both the anterior gastric antrum and the posterior splenic vein. The lymph nodes then extend along the entire hepatoduodenal ligament. As far as possible, no other solid masses were identified either in the cephalic pancreatic body region or on the walls of the gastric antrum itself. The Wirsung and splenoportal axis were not dilated. The liver was also free of pathological foci."




I recommend an immediate level II assessment with contrast-enhanced abdominal examination (CT + contrast medium), which confirms the ultrasound findings, showing that the larger lesion in the pancreatic body corresponds in terms of vascularization and marginal characteristics to suspected primary pancreatic adenocarcinoma; "the presence of a dyskaryokinetic lesion of the pancreatic isthmus with predominantly exophytic growth of approximately 34 mm in maximum diameter is noted, associated with dilation of the Wirsung's duct downstream of the lesion. No evident signs of vascular encasement at this level. No focal lesions of the liver are appreciable. Presence of multiple lymphadenopathies confluent in bundles at the level of the lesser gastric curvature, at the level of the hepatic hilum, at the interportal caval site, at the aortic intercavium and left para-aortic site, the largest of which at the lesser gastric curvature measuring approximately 30 mm."



The Cisanello medical oncology department was contacted for a preliminary evaluation, including a surgical one, but the patient independently decided, due to having reached the age limit, not to undergo any chemotherapy or surgery. The patient died approximately 15 months after the ultrasound diagnosis. A subsequent analysis of the organs at the Cisanello pathology department confirmed the initial diagnosis of pancreatic adenocarcinoma.








Pancreatic adenocarcinoma is the most common type of pancreatic neoplasm, as it accounts for about 85% of cases, and the term “pancreatic cancer” is sometimes used to refer only to this type. Adenocarcinomas originate in the cells that make up the part of the organ responsible for producing digestive enzymes. However, the various other types of tumors, which together represent the majority of non-adenocarcinomas, can also derive from these cells. Among every one hundred cases of pancreatic cancer, between one and two are of the neuroendocrine type (called “PanNETs” or Pancreatic Neuroendocrine Tumors), meaning they originate from the cells that produce pancreatic hormones; they generally have a less aggressive course compared to adenocarcinoma. The most common signs and symptoms of the disease may include yellowing of the skin, abdominal or back pain, unexplained weight loss, pale-colored stools, dark urine, and loss of appetite. Usually, in the early stages of the disease, symptoms do not appear or are not sufficiently specific to raise the suspicion of a neoplasm. This results in a frequent delay in diagnosis, which is often made only when the tumor is already at an advanced stage and has spread to other parts of the body [2][3][4]. Pancreatic cancer rarely occurs before the age of 40, and more than half of pancreatic adenocarcinoma cases involve people over the age of seventy. The risk factors for these neoplasms include tobacco smoking, obesity, diabetes, and some rare genetic diseases. About 25% of cases are linked to smoking [5] and 5%-10% are related to inherited genes.

The many types of pancreatic tumors can be divided into two generalized groups. The vast majority of cases (about 99%) occur in the portion of the organ responsible for producing digestive enzymes, known as the exocrine pancreas. There are several subtypes of exocrine pancreatic tumors, but their diagnosis and treatment have many points in common. The small minority of tumors that arise in endocrine tissue, which produces pancreatic hormones, have different clinical characteristics. Both groups mostly—but not exclusively—affect individuals over the age of 40, with a slightly higher prevalence in males; however, some rare subtypes occur mainly in women or in children [15][16].

EXOCRINE TUMORS:
The group of exocrine tumors is dominated by pancreatic adenocarcinomas (some variations of this name may include the attribute "invasive" or "ductal"), which by far represent the most common type, accounting for about 85% of all pancreatic tumors [2], despite the fact that the tissue from which they originate, the pancreatic ductal epithelium, represents less than 10% of the organ’s cell volume [17]. The exact origin is to be found in the ducts of the pancreas’s exocrine secretions, such as enzymes and bicarbonate.

The second most common type is acinar cell carcinoma of the pancreas, which originates from the cells that produce enzymes, accounting for 5% of exocrine pancreatic tumors [18]. These carcinomas can cause an excessive production of certain molecules, in this case digestive enzymes, which sometimes lead to the occurrence of paraneoplastic symptoms such as skin rashes and joint pain.

Cystadenocarcinoma represents only 1% of pancreatic tumors and has a better prognosis compared to other exocrine types [18].
Pancreatoblastoma is a rare form, typical mainly in childhood, with a relatively good prognosis. Other exocrine tumors include adenosquamous carcinoma, signet ring cell carcinoma, hepatoid carcinoma, colloid carcinoma, undifferentiated carcinoma, and undifferentiated carcinomas with osteoclast-like giant cells.
Solid pseudopapillary tumor is a rare, low-grade neoplasm that mainly affects young women and generally has a good prognosis [2][19].
Mucinous cystic neoplasms of the pancreas form a large group of pancreatic tumors that have various malignant potentials and are the subject of much debate regarding their assessment and treatment, since in many cases they behave benignly [20].

NEUROENDOCRINE TUMORS:
The small minority of tumors that arise in other portions of the pancreas consists mainly of pancreatic neuroendocrine tumors (called "PanNETs" or Pancreatic Neuroendocrine Tumors) [21]. Neuroendocrine tumors (NETs) are a heterogeneous group of benign or malignant tumors that originate from the body’s neuroendocrine cells, which are responsible for integrating the nervous and endocrine systems. NETs can arise in various organs of the body, including the pancreas itself, and malignant variants are considered rare.

PanNETs are grouped into “functioning” and “non-functioning” types, depending on their ability to produce hormones. The functioning types secrete hormones such as insulin, gastrin, and glucagon into the blood, often in large quantities, leading to serious symptoms such as hypoglycemia, but this generally allows for a relatively early diagnosis. The most common functioning PanNETs are insulinomas and gastrinomas, named after the hormones they secrete. Non-functioning types do not secrete hormones in sufficient quantities to cause obvious clinical symptoms. For this reason, non-functioning PanNETs are often diagnosed only after the tumor has spread to other parts of the body [22].

As with other neuroendocrine tumors, the nomenclature and classification of PanNETs is sometimes complex [21]. They are referred to as “islet cell tumors,” although it is now known that they do not actually originate from islet cells as previously believed [22].

EPIDEMIOLOGY:
In 2012, pancreatic cancer caused 330,000 deaths worldwide [4], a figure steadily increasing compared to the 310,000 deaths recorded in 2010 and 200,000 in 1990 [24]. It is estimated that in 2014, in the United States alone, 46,000 people were diagnosed with pancreatic cancer, and 40,000 deaths were caused by it. Even though it represents only 2.5% of newly diagnosed cancer cases, pancreatic cancer is responsible for 6% of cancer deaths each year [25]. It is the seventh leading cause of cancer death worldwide [4]. Globally, pancreatic cancer is the 11th most common cancer among women and the 12th most common among men [4]. Most recorded cases occur in developed countries [4].
Pancreatic adenocarcinoma is the most common type of pancreatic neoplasm, as it accounts for about 85% of cases, and the term “pancreatic cancer” is sometimes used to refer only to this type. Adenocarcinomas originate in the cells that make up the part of the organ responsible for producing digestive enzymes. However, the various other types of tumors, which together represent the majority of non-adenocarcinomas, can also derive from these cells. Among every one hundred cases of pancreatic cancer, between one and two are of the neuroendocrine type (called “PanNETs” or Pancreatic Neuroendocrine Tumors), meaning they originate from the cells that produce pancreatic hormones; they generally have a less aggressive course compared to adenocarcinoma. The most common signs and symptoms of the disease may include yellowing of the skin, abdominal or back pain, unexplained weight loss, pale-colored stools, dark urine, and loss of appetite. Usually, in the early stages of the disease, symptoms do not appear or are not sufficiently specific to raise the suspicion of a neoplasm. This results in a frequent delay in diagnosis, which is often made only when the tumor is already at an advanced stage and has spread to other parts of the body [2][3][4]. Pancreatic cancer rarely occurs before the age of 40, and more than half of pancreatic adenocarcinoma cases involve people over the age of seventy. The risk factors for these neoplasms include tobacco smoking, obesity, diabetes, and some rare genetic diseases. About 25% of cases are linked to smoking [5] and 5%-10% are related to inherited genes.

The many types of pancreatic tumors can be divided into two generalized groups. The vast majority of cases (about 99%) occur in the portion of the organ responsible for producing digestive enzymes, known as the exocrine pancreas. There are several subtypes of exocrine pancreatic tumors, but their diagnosis and treatment have many points in common. The small minority of tumors that arise in endocrine tissue, which produces pancreatic hormones, have different clinical characteristics. Both groups mostly—but not exclusively—affect individuals over the age of 40, with a slightly higher prevalence in males; however, some rare subtypes occur mainly in women or in children [15][16].

EXOCRINE TUMORS:
The group of exocrine tumors is dominated by pancreatic adenocarcinomas (some variations of this name may include the attribute "invasive" or "ductal"), which by far represent the most common type, accounting for about 85% of all pancreatic tumors [2], despite the fact that the tissue from which they originate, the pancreatic ductal epithelium, represents less than 10% of the organ’s cell volume [17]. The exact origin is to be found in the ducts of the pancreas’s exocrine secretions, such as enzymes and bicarbonate.

The second most common type is acinar cell carcinoma of the pancreas, which originates from the cells that produce enzymes, accounting for 5% of exocrine pancreatic tumors [18]. These carcinomas can cause an excessive production of certain molecules, in this case digestive enzymes, which sometimes lead to the occurrence of paraneoplastic symptoms such as skin rashes and joint pain.

Cystadenocarcinoma represents only 1% of pancreatic tumors and has a better prognosis compared to other exocrine types [18].
Pancreatoblastoma is a rare form, typical mainly in childhood, with a relatively good prognosis. Other exocrine tumors include adenosquamous carcinoma, signet ring cell carcinoma, hepatoid carcinoma, colloid carcinoma, undifferentiated carcinoma, and undifferentiated carcinomas with osteoclast-like giant cells.
Solid pseudopapillary tumor is a rare, low-grade neoplasm that mainly affects young women and generally has a good prognosis [2][19].
Mucinous cystic neoplasms of the pancreas form a large group of pancreatic tumors that have various malignant potentials and are the subject of much debate regarding their assessment and treatment, since in many cases they behave benignly [20].

NEUROENDOCRINE TUMORS:
The small minority of tumors that arise in other portions of the pancreas consists mainly of pancreatic neuroendocrine tumors (called "PanNETs" or Pancreatic Neuroendocrine Tumors) [21]. Neuroendocrine tumors (NETs) are a heterogeneous group of benign or malignant tumors that originate from the body’s neuroendocrine cells, which are responsible for integrating the nervous and endocrine systems. NETs can arise in various organs of the body, including the pancreas itself, and malignant variants are considered rare.

PanNETs are grouped into “functioning” and “non-functioning” types, depending on their ability to produce hormones. The functioning types secrete hormones such as insulin, gastrin, and glucagon into the blood, often in large quantities, leading to serious symptoms such as hypoglycemia, but this generally allows for a relatively early diagnosis. The most common functioning PanNETs are insulinomas and gastrinomas, named after the hormones they secrete. Non-functioning types do not secrete hormones in sufficient quantities to cause obvious clinical symptoms. For this reason, non-functioning PanNETs are often diagnosed only after the tumor has spread to other parts of the body [22].

As with other neuroendocrine tumors, the nomenclature and classification of PanNETs is sometimes complex [21]. They are referred to as “islet cell tumors,” although it is now known that they do not actually originate from islet cells as previously believed [22].

EPIDEMIOLOGY:
In 2012, pancreatic cancer caused 330,000 deaths worldwide [4], a figure steadily increasing compared to the 310,000 deaths recorded in 2010 and 200,000 in 1990 [24]. It is estimated that in 2014, in the United States alone, 46,000 people were diagnosed with pancreatic cancer, and 40,000 deaths were caused by it. Even though it represents only 2.5% of newly diagnosed cancer cases, pancreatic cancer is responsible for 6% of cancer deaths each year [25]. It is the seventh leading cause of cancer death worldwide [4]. Globally, pancreatic cancer is the 11th most common cancer among women and the 12th most common among men [4]. Most recorded cases occur in developed countries [4].


BIBLIOGRAFY
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22. ^ Salta a:a b c d e f g Burns WR, Edil BH, Neuroendocrine pancreatic tumors: guidelines for management and update, in Current treatment options in oncology, vol. 13, n. 1, March 2012, pp. 24-34, DOI:10.1007/s11864-011-0172-2, PMID 22198808.
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