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 : 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. 2 nd 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 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( 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, 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 Cystic Tumors of the Pancreas: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Features Radiographics 11/ :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