Fig. 2.

53-year-old man with stage IV pancreatic body cancer and liver metastasis.

A. Contrast-enhanced CT (September 19, 2008) taken before start of concurrent chemotherapy and high intensity focused ultrasound therapy shows irregular soft tumor tissue (short white arrows) at pancreatic head with invasion to distal common bile duct. Multiple necrotic nodes (long white arrows) are shown in mesentery. Common bile duct contains metallic stent. Small hypodense lesion (black arrow) is present in segment 5, indicating metastasis.

B. Contrast-enhanced CT (May 15, 2009) taken after 4 sessions of concurrent chemotherapy and high intensity focused ultrasound therapy and 3 sessions of high intensity focused ultrasound therapy alone shows remarkable interval decrease of tumor size (arrows). Necrotic nodes present in mesentery were also reduced in size, and liver nodule disappeared (not shown).

C. Surgical specimen of pancreas after pylorus preserving pancreaticoduodenectomy (November 11, 2009) shows irregular whitish tumor (arrows) in pancreatic head. Pathological diagnosis was poorly differentiated adenocarcinoma.

D. Contrast-enhanced CT (January 9, 2010) taken two months after surgery shows reappearance of liver nodule (short arrows) in segment 5, suggesting relapse of liver metastasis. Slightly enlarged portocaval node was also observed (long arrow).

E. First plot shows change in CA 19-9 concentration with time. CA 19-9 level was increased again approximately 10 months after initial treatment. Second plot shows change of tumor size (determined by CT) with time. After initial regression, size of tumor remained relatively stable until surgery. Third plot shows dates and number of chemotherapy sessions prior to enrollment and dates of concurrent chemotherapy and high intensity focused ultrasound (HIFU) therapy (CCHT) or high intensity focused ultrasound alone treatment.