Schwannoma mimicking pancreatic carcinoma: A case report

BACKGROUNDSchwannoma of the pancreas is extremely rare. We report a case of pancreatic schwannoma that was difficult to distinguish from pancreatic carcinoma before surgery.CASE SUMMARYA 66-year-old male underwent a right-lobe hepatectomy for hepatocellular carcinoma. Post-surgical computed tomography showed a 10 mm long solid mass with ischemia, with no expansion into the main pancreatic duct. Upon magnetic resonance cholangiopancreatography, the tumor had high signal intensity in diffusion weighted images, consistent with pancreatic carcinoma. Endoscopic ultrasound (EUS) was performed to obtain more information about the tumor, and showed a 14 mm solid and hypoechoic mass in the pancreatic body. Contrast enhanced EUS revealed that the tumor showed a hyperechoic mass in the early phase, and the contrasting effect continuation was very short; findings also consistent with pancreatic carcinoma. Thus, we preoperatively diagnosed his condition as a pancreatic carcinoma and performed distal pancreatectomy with splenectomy. Microscopic examination showed that the tumor was in fact a benign schwannoma. Histology showed a proliferation of spindle-shaped cell in a vague fascicular and haphazard pattern, with palisading arrangement.CONCLUSIONSchwannoma of the pancreas is very rare, however, clinicians should consider schwannoma as the differential diagnosis for pancreatic tumors.     

Sarcomatoid carcinoma of the pancreas — multimodality imaging findings with serial imaging follow-up: A case report and review of literature

BACKGROUNDSarcomatoid carcinoma of the pancreas is extremely rare and has an extremely poor prognosis. Although a few cases of sarcomatoid carcinoma of pancreas have been reported, most are focused on a histopathological review. To the best of our knowledge, there are no reports documenting multimodality imaging characteristics and chronological changes with emphasis on radiologic features.CASE SUMMARYA 64-year-old woman was admitted to Chungnam National University Hospital with acute appendicitis. Contrast-enhanced computed tomography of the abdomen revealed a 2.6 cm × 2.8 cm multilobular cystic mass in the pancreatic tail. The pancreatic lesion showed suspected mural nodules and thin septa. Hence, mucinous cystic neoplasm of pancreas was considered. After 7 mo, the patient was readmitted for repeated epigastric abdominal pain and nausea. Follow-up contrast-enhanced computed tomography of the abdomen and magnetic resonance imaging revealed a marked enlargement (5.4 cm × 4 cm), with a predominant internal solid component. The mass showed low signal intensity on a T1-weighted image and heterogeneously intermediate high signal intensity on a T2-weighted image. It showed diffusion restriction and peripheral rim enhancement on an arterial phase image, and progressive enhancement on portal venous and delayed phase images. Distal pancreatectomy was performed. Based on the morphology and immunohistochemical staining of the specimen, pancreatic sarcomatoid carcinoma was diagnosed.CONCLUSIONWe present the computed tomography, magnetic resonance imaging, and positron emission tomography computed tomography findings, pathologic features, and chronological changes for preoperative diagnosis.     

Pancreatic carcinoid tumor with obstructive pancreatitis: multislice helical CT appearance: case report

Carcinoid tumor of the pancreas is rare. Moreover, obstructive pancreatitis secondary to a pancreatic carcinoid tumor is extremely rare. We report a case of pancreatic carcinoid tumor in a 50-year-old male who presented with pancreatitis. On multislice helical computed tomography, the main pancreatic duct was obstructed by a small round tumor, and the main pancreatic duct proximal to the tumor was dilated. The correlation between the main pancreatic duct and the tumor was well depicted on minimum intensity projection image. This is the first report of multislice helical computed tomorgraphic and minimum intensity projection image findings of a pancreatic carcinoid tumor presenting with pancreatitis     

Pancreatic metastasis from squamous cell lung cancer: computed tomography and magnetic resonance imaging findings

Metastatic lesions of the pancreas are uncommon. The incidence of pancreatic involvement with squamous cell carcinoma is the lowest among the different histological subtypes of lung cancer. We present the clinical data, pathological findings, and imaging features of two cases of pancreatic metastasis from squamous cell lung cancer with a literature review. A 75-year-old man and a 67-year-old man were both diagnosed with metastatic pancreatic tumors from squamous cell lung cancer during a multidisciplinary team discussion. Both patients were misdiagnosed as having a neuroendocrine tumor of the pancreas by imaging examination before surgery. Squamous cell lung cancer metastasis to the pancreas is extremely rare, and the atypical clinical and radiological presentations make it difficult to distinguish metastatic tumors from primary pancreatic tumors.     

Laparoscopic distal pancreatectomy for hemosuccus pancreaticus due to an intraductal papillary mucinous neoplasm

Hemosuccus pancreaticus (HP) is a condition that is defined as gastrointestinal hemorrhage which occurs through the pancreatic duct. We present the rare case of a 75-year-old woman who developed HP caused by intraductal papillary mucinous neoplasm (IPMN). She had been followed for sarcoidosis, splenic artery aneurysm and pancreatic cyst. The patient presented to the emergency room of our hospital with epigastric pain and bloody discharge. Computed tomography revealed hemorrhage from a splenic artery aneurysm in a cystic lesion of the pancreas. On angiography, extravasation from the splenic artery was observed. Thus, we performed coil embolization. After interventional radiography (IVR), magnetic resonance imaging and endoscopic retrograde pancreatography showed a branch duct IPMN. Based on these findings, elective laparoscopic distal pancreatectomy was performed. The histopathological diagnosis was IPMN with HP caused by rupture of a splenic artery aneurysm. For such complicated cases, minimally invasive surgery is applicable after successful hemostasis by IVR.     

Successful outcome of retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts: A case report

BACKGROUNDChronic pancreatitis occasionally requires surgical treatment that can be performed with various techniques. Often, this type of surgery presents with postoperative complications. We report a case of a successful retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts.CASE SUMMARYA 62-year-old male with a 10-year history of chronic pancreatitis presented with epigastric pain for one week and a 20 kg weight loss over one year. Computed tomography showed stones in the pancreas (mainly the head), expansion of the main pancreatic duct, and thinning of the pancreatic parenchyma. Magnetic resonance imaging showed infected pancreatic cysts connected to the stomach with a fistula from the splenic hilum to the caudal portion of the liver’s lateral segment. An endoscopic retrograde pancreatography was performed; the guide wires could not pass through the stones in the pancreas and therefore, drainage of the main pancreatic duct was not achieved. Next, a distal pancreatomy and splenectomy were performed; however, the pancreatic juice in the remaining parenchyma was blocked by the stones. Hence, we performed a retrograde pancreatojejunostomy and Roux-en-Y anastomosis. The patient had no postoperative complications and was discharged from the hospital on postoperative day 14.CONCLUSIONA distal pancreatomy, retrograde pancreatojejunostomy, and Roux-en-Y anastomosis could be an effective surgical procedure for intractable chronic pancreatitis.     

A case of accessory hepatic duct entering cystic duct successfully treated by laparoscopic cholecystectomy for cholecystolithiasis

Although laparoscopic cholecystectomy is a well-established surgical procedure, an accessory hepatic duct (AcHD) entering the cystic duct is poorly understood. A 77-year-old woman with symptomatic cholecystlithiasis was referred to our hospital. Abdominal ultrasonography indicated several small stones in the gall bladder. Magnetic resonance cholangiopancreatography (MRCP) did not reveal an anomalous cystic duct. Dissecting the gall bladder bed at operation, AcHD entering the cystic duct was suspected. Intraoperative cholangiography revealed that B5 branch entered the cystic duct. We ligated the AcHD, and divided it. Laparoscopic cholecystectomy was completed, and the patient was discharged without any complication. A week after the operation, MRCP showed that ventral branch of B5 was dilated. The patient showed no symptom for more than a year. The present case exhibited extremely rare AcHD entering the cystic duct, which was hardly recognized before surgery. It is possible to recognize such anomalous variants with standard laparoscopic approach based on 2018 Tokyo Guidelines and with attention to the possibilities of AcHD entering the cystic duct.     

Obstructive jaundice due to isolated tuberculosis of the pancreas: endoscopic treatment instead of surgery?

The optimal treatment for relieving biliary obstruction due to isolated pancreatic tuberculosis has not so far been defined, and most previously reported patients were treated surgically. We describe a 17-year-old, immunocompetent girl who was admitted with obstructive jaundice caused by a tuberculous mass in the head of the pancreas. Antituberculous therapy alone failed to alleviate the jaundice, and she was therefore treated by stent insertion and, subsequently, balloon dilation of the common bile duct stricture. At follow-up 5 years later, magnetic resonance cholangiopancreatography showed no evidence of stricture in the common bile duct.     

Double plastic stent implantation for recurrent acute pancreatitis with incomplete pancreas divisum: a case report and literature review

Pancreas divisum (PD) is a common pancreatic malformation caused by the failure of fusion between ventral and dorsal pancreatic ducts. There is a small branch of communication between the two systems in incomplete PD, and this variation has an incidence of 15%. A 43-year-old female patient presented to our department with recurrent abdominal pain. Magnetic resonance cholangiopancreatography (MRCP) showed that the ventral pancreatic duct was curved, with a local pouchlike dilatation. Endoscopic ultrasonography supported the diagnosis of incomplete PD and showed a thin branch of communication between ventral and dorsal pancreatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy of the minor papilla with double plastic stent implantation were performed. One pancreatic plastic stent was inserted across the minor and major papilla over the guide wire, creating a U-shape. The other wire-guided plastic stent was inserted through the minor papilla into the dorsal pancreatic duct. The pancreatic fluid drained smoothly after stent placement. During the 6-month follow-up, the patient remained well, without recurrence of pancreatitis.     

Mesenteric heterotopic pancreas in a pediatric patient: A case report and review of literature

Heterotopic pancreas (HP) is a congenital anomaly defined as pancreatic tissue that has no contact with the orthotopic pancreas and its own duct system and vascular supply. The most common locations of HP are the upper gastrointestinal tract, specifically, the stomach, duodenum, and proximal jejunum. Involvement of the mesentery is rare. Here, we describe a rare case of mesenteric heterotopic pancreas (MHP) in a 12-year-old girl who presented with acute abdomen. The patient underwent emergency laparotomy, and the mass and adjacent small bowel were resected. Results of the postoperative histopathologic examination confirmed the diagnosis of MHP. Observation of the patient for 12 mo postoperatively showed no evidence of recurrence. Preoperative diagnosis of HP is difficult, even in a symptomatic patient. Increased awareness and understanding of the image characteristics of MHP will aid in correct preoperative diagnosis and appropriate patient management.     

Multiple ectopic goiter in the retroperitoneum,abdominal wall,liver, and diaphragm: A case report and review of literature

BACKGROUNDEctopic thyroid is a rare developmental disorder, typically found in lingual areas, and most distantly in the abdomen. Thyroid ectopia in multiple regions is extremely rare. To date, there are no reports of ectopic goiter in four regions of the abdominal cavity in a single patient.CASE SUMMARYWe present a case of thyroid ectopia in four areas of the abdomen, comprising normal orthotopic thyroid tissue. A 36-year-old woman, who underwent ovarian teratoma resection 10 years previously due to symptomatic ovarian teratoma, was referred to our hospital for treatment of an incidental hepatic mass. Magnetic resonance imaging and computed tomography (CT) of the abdomen showed a heterogeneously enhanced lobulated lesion in the sixth and seventh hepatic segment adjacent to the diaphragm. The mass was surgically excised, and histologic examination determined an ectopic nodular goiter. At the one-year follow-up, the abdominal CT scan, whole-body radionuclide I131 examination, and abdominal wall biopsy showed similar lesions in the left renal fascia and anterior abdominal wall.CONCLUSIONMultiple para-ectopic thyroid is often misdiagnosed, owing to its extremely rare incidence and non-specific clinical manifestations and imaging features. A combination of multiple examinations is necessary for diagnostic accuracy.     

Solitary metastasis from renal cell carcinoma presenting as diffuse pancreatic enlargement

Late metastasis of renal cell carcinoma (RCC) to the pancreas is uncommon. Diffuse pancreatic metastasis of any carcinoma rarely causes global enlargement of the pancreas. We present the case of a 73-year-old man diagnosed with metastatic RCC of the pancreas 9 years after radical nephrectomy had been performed and describe our radiologic findings. The disease involved the entire pancreas, which was hypoechoic on sonography, hypodense on CT without contrast enhancement, and markedly hyperdense after intravenous administration of a contrast agent. Color Doppler sonography showed that the involved areas of the pancreas had increased color flow signals, indicating that the metastatic tumor was characteristically hypervascular. In patients with a history of RCC, color or power Doppler sonographic demonstration of diffuse enlargement of the pancreas with evidence of hypervascularity may indicate metastasis of RCC to the pancreas.     

Tumor-associated focal chronic pancreatitis from invasion of the pancreatic duct by common bile duct carcinoma: radiologic-pathologic correlation

We report a case of tumor-associated focal chronic pancreatitis of the uncinate process of the pancreas. The chronic pancreatitis was secondary to stenosis of the main pancreatic duct from invasion by a common bile duct carcinoma. A feature distinguishing the chronic pancreatitis from pancreatic carcinoma was the localized dilatation of pancreatic duct branches evident in the focal lesion of the uncinate process.     

Tumor-associated focal chronic pancreatitis from invasion of the pancreatic duct by common bile duct carcinoma: radiologic–pathologic correlation

We report a case of tumor-associated focal chronic pancreatitis of the uncinate process of the pancreas. The chronic pancreatitis was secondary to stenosis of the main pancreatic duct from invasion by a common bile duct carcinoma. A feature distinguishing the chronic pancreatitis from pancreatic carcinoma was the localized dilatation of pancreatic duct branches evident in the focal lesion of the uncinate process.     

Multiple comet tail artifacts in the liver: a case of congenital hepatic fibrosis showing unusual biliary appearance

Congenital hepatic fibrosis (CHF) is a form of autosomal recessive polycystic kidney disease. Because of the common underlying pathophysiology of ductal plate malformation, CHF can be accompanied by an abnormal biliary appearance, which is characterized by a saccular or fusiform dilatation of the bile ducts. We encountered the case of a 35-year-old man suffering from CHF concomitant with esophageal varices, which were treated by endoscopic sclerotherapy. The patient had elevated serum concentrations of alkaline phosphatase and γ-glutamyl transpeptidase without apparent biliary disease, including hepatolithiasis or a history of cholangitis. Magnetic resonance cholangiography showed an abnormal biliary appearance, which was not saccular or fusiform but had multiple stenosis with unknown causes. B-mode sonogram showed multiple comet tail artifacts in the liver parenchyma, probably corresponding to the compact fibrosis bands and bile in the bile duct as well as peripheral bile duct dilatation, which was proven pathologically. We propose that multiple comet tail artifacts in the liver may suggest the presence of a bile duct abnormality in patients with CHF, suggesting the potential risk for developing biliary complications.     

36例胰头癌超声内镜诊断分析

目的 总结分析胰头癌的超声内镜的影像学表现与诊断。方法 回顾性分析36例胰头癌的超声内镜、体外B超、螺旋CT的影像学表现、肿瘤学标记物测定，总结其特点。结果 超声内镜下胰头癌主要表现为边界不清晰（22／32）的低回声（21／32），伴有胆总管和胰管的扩张（19／36）、血管的侵犯（26／32）；EUS检查的诊断正确率为65．6％（21／32），判断肿瘤的血管浸润及淋巴结转移准确率均为81．3％（26／32）；体外B超三者的准确率分别为43、8％（14／32）、43．8％（14／32）、563％（18／32）；螺旋CT三者的准确率分别为59．4％（19／32）、81．3％（26／32）、68．8％（22／32）。患者CA19-9测定显著升高，CA125和CEA大多正常。结论 超声内镜准确判断胰头癌仍需进一步积累经验；本组资料中，螺旋CT的诊断准确率、判断淋巴结转移及周围血管侵犯准确率与EUS比较无明显优越性。EUS与螺旋CT结合，对胰头癌的术前诊断和可切除性判断具重要价值。     

Mucinous cystadenomas and intraductal papillary mucinous tumors of the pancreas in magnetic resonance cholangiopancreatography

BACKGROUND AND STUDY AIMS: In mucin-producing tumors of the pancreas, diagnosis using endoscopic retrograde cholangiopancreatography (ERCP) is limited to cystic formations that communicate with the main pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) is a new, sophisticated method which is currently under evaluation. The authors describe the usefulness of MRCP in diagnosis of mucin-producing tumors. PATIENTS AND METHODS: Six patients with mucin-producing tumors were investigated using MRCP and ERCP. Imaging was compared with surgery and histopathological examinations. RESULTS: Three patients were found to have mucinous cystadenomas (MC), two patients had intraductal papillary mucinous tumors (IPMT) and one patient had a cystadenocarcinoma. MRCP demonstrated the cystic formations in all patients. Magnetic resonance imaging (MRI) showed contrast-mediated enhancement of the cystic wall in patients with MC, and visualized the pancreatic ducts completely in patients with IPMT. ERCP failed to visualize the cystic lesion in one patient with MC of the pancreatic tail. Furthermore, ERCP showed evidence of IPMT in dilated main ducts with multiple filling defects but did not visualize the ducts completely. CONCLUSIONS: MRCP provides visualization of pancreatic ducts, extraductal variations, and cystic formations more completely than ERCP does. It avoids complications seen in ERCP. MRCP may replace ERCP in the evaluation of mucin-producing tumors of the pancreas.     

Magnetic resonance pancreatography (MRP)

Magnetic resonance pancreatography (MRP) is a technique that permits accurate evaluation of the pancreatic duct without instrumentation, contrast material administration, or ionizing radiation. Because MRP is entirely noninvasive, MRP avoids complications associated with endoscopic retrograde pancreatography (ERP) such as pancreatitis and perforation. MRP allows for the noninvasive evaluation of patients with acute and chronic pancreatitis, variant anatomy of the pancreatic duct, pancreatic duct trauma, and pancreatic neoplasia. MRP yields diagnostic information in the setting of a failed or incomplete ERP. When MRP is performed in conjunction with conventional abdominal MR, the result is a comprehensive examination of the pancreatic duct as well as the pancreas and other solid organs of the abdomen.     

Pediatric subhepatic appendicitis with elevated lipase

Appendicitis is the most common surgical emergency in children, of which most are located in the retrocecal space or pelvis. Appendicitis occurring in the subhepatic space is uncommon and may present with atypical features such as right upper quadrant pain, leading to delayed diagnosis and complications. We present a rare case of subhepatic appendicitis in an 11-year-old female, who presented with a three-day history of both right upper quadrant (RUQ) and right lower quadrant (RLQ) abdominal pain and serum lipase elevated four times the upper normal limit. The abdominal ultrasound was normal, except for prominent RLQ abdominal lymph nodes. Hours later, a computed tomography scan revealed a non-ruptured subhepatic appendicitis and normal pancreas. Our patient encounter demonstrates the need to be aware of the atypical presentations of pediatric appendicitis in general and subhepatic appendicitis in particular. Moreover, to our knowledge, this is the first reported case of elevated lipase (with a radiographically normal pancreas) in association with subhepatic appendicitis. Providers should be aware elevated serum lipase levels may be due to conditions other than pancreatitis and further evaluation should be considered if the elements of the clinical picture are incongruent.