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A 79-year-old man presented with signs of biliary obstruction (bilirubin 82 μmol/L, alanine aminotransferase 358 IU/L and alkaline phosphatase 250 IU/L) and normocytic anaemia (haemoglobin 120 g/L). He had a 4-month history of relapsed multiple myeloma and had been treated with five cycles of bortezomib (a proteasome inhibitor). Transabdominal ultrasound demonstrated an ill-defined mass in the pancreatic head associated with upstream biliary dilatation. CT demonstrated multiple uniformly enhancing soft tissue masses throughout the pancreas with enlargement of the pancreatic head, in particular, and associated biliary obstruction. There was a direct invasion into the main portal vein, suggesting a solid malignancy. There was no evidence of distal metastases, ascites or peritoneal carcinomatosis (figure 1). Immunoglobulin (Ig) G4 levels were normal but IgG2 …
Contributors MJK and JB were involved in the literature review and drafted the manuscript layout, text content and sourcing images. MJK, JB, RA and MTH were involved in revisions of the manuscript layout and content. AW and AC advised on histopathology input and provided the demonstrative histopathology image.
Funding This research has received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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