Introduction

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 …