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