Case Study : Hepato –Pancreatico Biliary

Dr.J.A.VenterDept.Imaging Sciences,Bloemfontein Academic Hospitals13/04/2012

Me.N.B.Mes 20 year old female refered to UH from Kby Hospital

post abdominal mass biopsy for further management.

Prior history : Healthy until blunt abdominal trauma in 2010 through a kick in the epigastrium during a football game followed by episode of severe abdominal pain and vommitting for which she was hospitalized for 3 days after which it subsided. 2nd similar episode with associated weight loss in 2011 not preceeded by trauma led to referral to the Kby hospital where a CT study of the abdomen and subsequent biopsy of a abdominal mass where performed on 24/12/2011.

Clinical/Special Examination Vitals normal ,No JACCOL Distended abdomen due a large

palpable epigastric mass extending into left and right hypochonrium.

FBC,U+E,LFT normal. S- amylase never elevated No documented episodes of PUD,

hypoglycemia or watery diarrhea

Surgical Findings : 08/02/2012 Large combined cystic and solid

pancreatic tumor with associated multiple peritoneal and omental nodules which were debulked including a splenectomy and tranvers colon resection due to vascular compromise .

Differential diagnosis of cystic pancreatic neoplasms: Non Neoplastic - Pseudocyst/Infective SCN MCN Intraductal Neoplasms (IPMN) Epithelial Neoplasms of uncertain direction of

differentiation -SPEN Cystic Pancreatic Endocrine Tumor(PET) Cystic Metastases Ductal Adenocarcinoma with cystic change Cystic Teratoma Lymphoepithelial cyst

Cyst Morphology

Serous Cystic Neoplasm(SCN) Women > 60 years – “ grandmother lesion” Slight predominance of occurrence in pancreatic

head. Coarsely calcified central scar with a sunburst

pattern. Can appear solid on CT – MRI most sensitive to

detect fluid. Consist of multiple(>6) small cysts < 2 cm in

diameter. Olygocystic variant < 6 cysts / > 2 cm difficult to

distinguish from MCN. Cyst fluid CEA < 192 ng/ml, Contain no mucin. Always benign – observation with serial imaging

of small asymptomatic lesions should be considered.

Mucinous Cystadenoma(MCN) Woman 50 years of age – “mothers lesion” Most common location in pancreatic tail Cysts typically > 2cm, < 6 Peripheral curvilinear calcifications and

mural nodules on CT. Biopsy unreliable – benign appearing

epithelium adjacent to invasive carcinoma. Graded pathologically by degree of

dysplasia – always surgical management. CEA > 192 ng/ml

Intraductal Papillary Mucinous Neoplasms(IPMN) Equally common in men and women . Main duct and side branch duct or combined variants.Can be

multiple. Main duct variant lead to dilatation of pancreatic duct to >

10 mm even if discrete lesion is not visualized, and has high malignant potential – surgical lesions

Side duct variant typically situated in uncinate process ,does not dilate the main duct and has lesser tendency to become malignant – < 3cm can be followed.

Adenoma – Carcinoma sequence – slow growing. Diagnosis based on demonstration of connection with ductal

system – MRCP. Patulous papil with mucin pouring from it a typical

endoscopic finding during ERCP. > CEA and Amylase (communicate with pancreatic duct)

SPEN(Solid Pseudopapillary Epithelial Neoplasm)

Tumor of younger woman(20 - 30 years ) – “daughter lesion”

Benign – low grade malignant tumor growing slowlly , but can rarely disseminate.

Encapsulated , large cystic - solid mass. Hypodense areas on CT represent

necrosis/bleeding in tumor. Excellent survival rates post resection -

warrant aggressive surgical approach.

Cystic Endocrine Tumor Syndromic or Non Syndromic. Peripheral rim enhancement – look for

hypervascular lesions in the liver. Should be differentiated from cystic

adeno carcinoma as aggressive surgery has a much better prognosis.

Cystic Metastases Sarcomas,Ovarian CA,Melanoma

metastases to pancreas RCC

Pseudocyst Typical unilocular cysts in/adjacent to

pancreas following a episode of acute pancreatitis or in the background of chronic pancreatitis.

Smooth non enhancing wall . Content ussualy rich in amilase >

250ng/dl May resolve with time compared to

neoplastic cysts that persists – follow in 4-6 weeks if uncertain.

References• Clinical Radiology (2007) 62, 930-937 An

evidence-based review for the management of cystic pancreatic lesions :A.C. Planner, E.M. Anderson*, A. Slater, J. Phillips-Hughes,H.K. Bungay, M. Betts

• Cystic Tumors of the Pancreas: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Features Seminars in Ultrasound, CT, and MRI, Volume 28, Issue 5, October 2007, Pages 339-356

• Radiographics 11/2005 1471 -1484 :Cystic Pancreatic Lesions: A Simple Imaging-based Classification System for Guiding Management

• Evaluation of Cystic Pancreatic Tumors over 3 cm in size – the role of 3D mapping in lesion definition,differential diagnosis and patient management – Ctisus.com - accessed 04/04/2012