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Case Study : Hepato – Pancreatico Biliary

Case Study : Hepato – Pancreatico Biliary . Dr.J.A.Venter Dept.Imaging Sciences,Bloemfontein Academic Hospitals 13/04/2012. Me.N.B.Mes. 20 year old female refered to UH from Kby Hospital post abdominal mass biopsy for further management . Prior history :

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Case Study : Hepato – Pancreatico Biliary

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  1. Case Study : Hepato –Pancreatico Biliary Dr.J.A.Venter Dept.ImagingSciences,Bloemfontein Academic Hospitals 13/04/2012

  2. 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.

  3. 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

  4. 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 .

  5. 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

  6. Cyst Morphology

  7. 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.

  8. 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

  9. 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)

  10. 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.

  11. 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.

  12. Cystic Metastases • Sarcomas,OvarianCA,Melanoma metastases to pancreas • RCC

  13. 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.

  14. 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 FeaturesSeminars 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

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