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X Ray Meeting

X Ray Meeting. Surgery Team 1. History. SKW, M/ 48yo Good past health Admitted in June 06 for 1 st episode of RUQ pain, fever and jaundice No previous history of pancreatitis Blood tests: WCC, amylase normal Bilirubin 66,ALP 250,ALT 465. Investigations. USG

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X Ray Meeting

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  1. X RayMeeting Surgery Team 1

  2. History • SKW, M/ 48yo • Good past health • Admitted in June 06 for 1 st episode of RUQ pain, fever and jaundice • No previous history of pancreatitis • Blood tests: WCC, amylase normal Bilirubin 66,ALP 250,ALT 465

  3. Investigations • USG • Private CT abdomen

  4. ?Benign or malignant?

  5. Progress • EUS and FNA done in July 06 • 5 cm cystic mass at the head of pancreas with no septum or mural nodule seen • Fluid sent for cytology, CEA and CA 19-9

  6. Progress • Fluid cytology : -ve for malignancy • CA 19.9 845 U/ml • CEA 2.93 ng/ml Impression : ? benign lesion

  7. Progress • Pylorus- preserving pancreatoduodenectomy (PPPD) was performed • Intra-op frozen section: no evidence of malignancy

  8. Progress • Pathology of specimen • borderline mucinous cystadenoma • Moderate dysplasia • Clear resection margin • Post op uneventful, discharged on day 10

  9. Discussion Cystic pancreatic neoplasm

  10. Introduction • Majority of cystic lesion in pancreas are pseudocyst (90-95%) • history of acute/chronic pancreatitis • Cystic neoplasm (< 10%) - various histology (Serous vs mucinous) • Certain grade of malignant potential in those other than serous type

  11. Clinical presentation • Non- specific • Most common presentations • abdominal pain • Jaundice

  12. Investigations • USG – cystic lesion • CT / MRI abdomen • Add diagnostic information only • Features suggestive of malignant potential includes intramural mass, thick wall, cystic dilatation of pancreatic duct not always present

  13. Investigations • EUS +/- FNA • Fluid for cytology, amylase, CEA, CA 19.9

  14. CEA 2.93ng/ml Gastrointestinal Endoscopy Volume 61, No. 3, 2005

  15. EUS +/- FNA • Risk of spillage of tumour cells • EUS alone: morphology inadequate for diagnosis - Fluid cytology :low cellular content • Tumour markers: No published cut-off values for clinical use

  16. Management • Decision of management based on (1) Symptoms (2) Risks of malignancy (3) Surgical risks of patient

  17. Management • Surgical treatment - Mainstay is resection • Low mortality rate • Good prognosis Current concepts: cystic neoplasms of the pancreas, New England Journal of Medicine,Sept 2004

  18. Summary • Case illustrating the challenging differentiation of cystic lesions despite various investigations • In good risks patient, surgical excision is the preferable treatment option • undergo EUS+FNA to guide decision making in patients with moderate surgical risks Brugge. Endoscopy July 2006

  19. The End Thank you!

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