Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.     

胰腺结核误诊为胰腺癌1例

结核累及胰腺非常罕见，临床症状有时不典型，术前诊断困难，现将中山医院收治的1例术前误诊为胰腺癌的胰腺结核报道如下。     

Minute carcinoma of the pancreas presenting as pancreatic pleural effusion

A 70-year-old Japanese man with no history of pancreatitis visited his local practitioner, complaining of dyspnea on effort. Left massive pleural effusion was detected and he was then referred to our hospital. A plain chest film showed marked left pleural effusion. Thoracentesis yielded 2000ml of bloody fluid with high amylase content (22665IU/l). Endoscopic retrograde pancreatography revealed a tapered occlusion of the main pancreatic duct. Pancreatic cancer was suspected, and a distal pancreatectomy and a splenectomy were performed. Histologically, the diagnosis was ductal adenocarcinoma of the pancreas, 5 × 6mm in size, with regional lymph node metastasis. He has experienced no recurrence of cancer or pleural effusion since the operation.     

Pathomorphologic study of undifferentiated carcinoma in seven cases: relationship between tumor and pancreatic duct epithelium

Background/purpose

By the time undifferentiated carcinoma is detected, it has formed a large mass, and it is reportedly difficult to pathologically observe its relationship with the pancreatic duct. In this study, we examined the pancreatic ducts of seven patients of surgical samples, and pathomorphologically investigated the relationship between the adenocarcinomatous and sarcomatous components and the pattern of tumor extension. In addition, we evaluated the usefulness of pancreatic juice cytology by comparison with the findings of the main pancreatic duct (MPD).

Methods

Seven primary undifferentiated carcinomas of the pancreas (from three male and four female patients with a mean age of 59 years) were analyzed. Histopathological evaluation was based on the WHO diagnostic criteria. Pancreatic juice cytology was performed and evaluated in two patients.

Results

All the undifferentiated carcinomas contained adenocarcinomatous and sarcomatous components, and two had a distinct glandular structure. However, we could not pathomorphologically confirm the continuity of the adenomatous with the sarcomatous components in any of the patients. Three undifferentiated carcinomas contained osteoclast-like giant cells. Pathological observation of the tumor and MPD was possible in three of the seven undifferentiated carcinomas. PanIN-3 was observed in the MPD of three patients, suggesting extension into the MPD. In one of these three, the tumor presented intraductal growth in the MPD, and preoperative pancreatic juice cytology revealed atypical cells with osteoclast-like giant cells. In the remaining two, the tumor extraductally compressed the MPD upward.

Conclusions

Undifferentiated carcinoma showed two patterns of cancer extension: (1) invasion and expansive growth during the sarcomatous transformation of adenocarcinoma, and (2) intraductal extension. In addition, some undifferentiated carcinomas showed extension in the MPD. Of note, postoperative pancreatic juice cytology may be useful for the diagnosis.     

Primary oral tuberculosis on the tongue mimicking squamous cell carcinoma

Tuberculosis is chronic granulomatous disease with rare oral manifestations. But if so are overlooked by most of the health care professionals. Clinically, most of the times, a tuberculous ulcer may mimic an ulcer of malignant origin and may be misdiagnosed. So, keeping in mind the etiology and the nature of the ulcer, it should be differentially diagnosed and a histopathological examination should only confirm the final diagnosis of the ulcer.     

Multi-centric pancreatic cancer without PanIN lesion

The patient was a 67-year-old man under follow-up after gastric cancer surgery. An abdominal CT scan performed 1 year earlier had shown an approximately 14-mm hypovascular mass in the pancreatic body; however, he did not consent to treatment and was followed up for 1 year. A blood workup showed that the fasting blood glucose level, which had been within normal limits, was elevated to 174 mg/dl (normal, 70–109 mg/dl), and the HbA1c level was 12.0% (normal, 4.3–5.8%). Abdominal CT revealed an approximately 20-mm mass in the pancreatic body and an approximately 12-mm mass in the pancreatic tail, and magnetic resonance imaging cholangiopancreatography (MRCP) showed discontinuity of the main pancreatic duct (MPD). Since these findings led to the suspicion of invasive ductal carcinoma (IDC) of the pancreas developing in the pancreatic body and tail, we performed distal pancreatectomy with splenectomy. Histologically, IDCs were observed in the pancreatic body and tail. However, PanIN was not observed in the MPD between the two carcinomas. They were diagnosed as independent invasive ductal carcinomas of the pancreas.     

Coexistence of pancreatic carcinoma and pancreatic tuberculosis: case report

Pancreatic tuberculosis (TB) is extremely rare and mimics pancreatic carcinoma both clinically and radiologically. This paper discusses the occurrence of 2 heterogeneous masses located in the head and tail of the pancreas in an adult male. In this patient, laparotomy was performed because of the high suspicion of pancreatic carcinoma. Intraoperative fine needle aspiration biopsy revealed the coexistence of pancreatic carcinoma with pancreatic TB, and a combined resection of the distal pancreas and spleen was successfully performed. Following surgery, the patient received standard chemotherapy for TB. At 7-month follow-up, computed tomography showed resolution of the mass in the pancreatic head. Clinicians must maintain a high index of suspicion for pancreatic TB in patients with pancreatic masses. The coexistence of malignancy and TB should be considered when patients present with multiple pancreatic masses.     

Staging and treatment for patients with pancreatic cancer. How small is an early pancreatic cancer?

To determine the tumor size that constitutes early pancreatic cancer, we reviewed and analyzed the English-language and Japanese literature (a total of 25 publications) on small pancreatic cancers less than 2 cm in diameter and/or stage 1 cancers. Reports on in situ carcinoma and intraductal carcinoma of the pancreas were also evaluated. The results were: (1) A total of 302 cases of small pancreatic cancer less than 2 cm in diameter reported at separate institutions were pooled from 15 reports. The rates for patients in stage I and those with no lymph node metastasis averaged 41.7% and 57.9%, respectively. The 5-year postoperative cumulative survival rate (5Y-PCR) was less than 50% in almost all these reports. Similar data were shown in the 7 collective reviews. (2) Another 33 cases of small pancreatic cancer of 1 cm or less in diameter were collected from three reports. The rates for stage I tumor and 5Y-PCR at one institution with two reports were 100% and 100% and the rates in the other report were 85% and 78%, respectively. (3) Twelve cases of in situ carcinoma and intraductal carcinoma of the pancreas were collected from four reports. All of the patients were stage I and were alive with no evidence of tumor recurrence for periods ranging from 6 to 78 months. Small pancreatic cancer less than 1 cm in diameter is better viewed as an early pancreatic cancer, and in situ carcinoma and intraductal carcinoma of the pancreas with minimal invasion to the pancreatic parenchyma may be defined as early pancreatic cancer, regardless of size.     

Focal pancreatic hemorrhage mimicking pancreas carcinoma with lymph node metastasis

A 67‐year‐old man was referred to our department because of a mass in the pancreas tail. Pancreatic tail cancer with lymph node metastasis was diagnosed, based on various radiological findings. Computed tomography (CT) revealed a slightly enhanced tumor mass around the celiac plexus, and endoscopic retrograde pancreatography (ERP) showed complete obstruction of the main pancreatic duct at the tail, although magnetic resonance imaging (MRI) demonstrated no elevation of the mean pixel value of the tumor after gadolinium (Gd) injection, and tumor markers of pancreas cancer were within normal limits. At surgery, the mass around the celiac plexus was found to be blood coagulation, and the pancreas tail tumor was found to be a focal hematoma in the pancreas. Pathologically, the hematoma was not encapsulated, and it was diagnosed as hemorrhage in the pancreas parenchyma. Both hemorrhagic lesions were suspected to have developed respectively. It is difficult to distinguish pancreas hemorrhage from carcinoma in the pancreas with chronic pancreatitis, especially when the hemorrhage is small in size and there are other extrapancreatic hemorrhagic lesions. For such diagnosis, the superiority of MRI with Gd injection is indicated.     

老年进展期胰腺癌98例临床研究

目的探讨进展期胰腺癌不同的治疗方法对预后的影响，以达到治疗的最优化。方法回顾性分析2002年11月至2005年9月收治的98例进展期胰腺癌，分为手术组（81例）：手术[行胆系和（或）肠系转流术、活检术等]加或不加辅助治疗；非手术组（17例）：行非手术治疗；并分析其治疗效果。结果手术组并发症发生率为17．3％（14／81）、病死率为4．9％（4／81），生存期平均为（2．9±2．3）年，加或不加辅助治疗其生存期分别为（2．9±3．7）年、（2．8±3．1）年；非手术组无并发症和死亡，生存期平均（2．7±2．1）年。结论对进展期无法行根治性切除术的胰腺癌、姑息性切除是无益的，对伴发胆系和（或）肠系梗阻时行转流术是必须的，围手术期辅助治疗是改善预后的重要方法。     

Precancerous conditions of pancreatic carcinoma

The precancerous conditions associated with pancreatic ductal carcinoma include preneoplastic duct changes and benign-looking tumors that give rise to ductal carcinomas. Among the duct changes that are discussed as precancerous lesions are hyperplastic and metaplastic lesions, which were recently classified as pancreatic intraepithelial neoplasia types 1A, 1B, 2, and 3. This new system is compared with the older terminology. Recent molecular findings concerning the most frequent genetic alterations in manifest carcinomas support the new classification system. The relative frequency of duct lesions in the nonneoplastic pancreas and their association with chronic pancreatitis and ductal carcinoma are discussed. Finally, the pancreatic exocrine tumors that may give rise to ductal carcinomas are presented.     

Utility of pancreatic duct brushing for diagnosis of pancreatic carcinoma

Background The aim of this study was to evaluate the usefulness of pancreatic duct brushing for diagnosis of pancreatic carcinoma. Methods Brush cytology was attempted in 58 patients suspected of having pancreatic malignancy because of stricture of the main pancreatic duct, confirmed by endoscopic retrograde cholangiopancreatography. Thirty-eight patients were finally diagnosed by an operation or the clinical course as having pancreatic carcinoma, and the remaining 20 patients as having chronic pancreatitis. The usefulness of brush cytology for diagnosis of pancreatic carcinoma was estimated. We interpreted failures of pancreatic duct brushing to be false negatives when the lesion was malignant. Results In 48 of 58 patients (82.8%), brushing was successfully performed and satisfactory specimens were obtained. Brush cytology was positive in 25 of 38 patients with pancreatic carcinoma (sensitivity 65.8%) and negative in all patients without malignancy (specificity 100%). Overall accuracy was 76.4%. During 2001–2005, the number of back-and-forth motions of the brush was increased to more than 30 times. The sensitivity significantly improved from 43.8% in 1997–2000 to 81.8% in 2001–2005 (P < 0.05). The increased success rate of brushing by improvement of skill in manipulating the guidewire and increased number of cells smeared on glass slides by increased back-and-forth motion of the brush may account for this improvement over time. Moreover, the sensitivity in 2001–2005 was 85.7% if failures of brushing with pancreatic carcinoma are excluded. No major complications occurred, except for two patients with a moderate grade of acute pancreatitis. Conclusions Although further studies with a large number of patients are needed, our results suggest that with recent improvements of the brushing technique, pancreatic duct brushing is a useful and safe method for the differential diagnosis of malignancy from benign diseases of the pancreas.     

Intrapancreatic pseudoaneurysm associated with pancreatitis mimicking pancreatic tumor

A 48-year-old man, who had suffered a bout of acute pancreatitis in September 2000, was found in March 2001 to have an increased concentration of serum amylase. A tumor in the pancreas body associated with stenosis and prestenotic dilatation of the main pancreatic duct was detected using imaging techniques. Distal pancreatectomy was performed under the diagnosis of pancreatic carcinoma. An intrapancreatic hematoma due to rupture of a pseudoaneurysm of the intrapancreatic artery was found in the resected specimen. This case illustrates how difficult it is to diagnose a small cancerous tumor in the pancreas and the rare presentation of this intrapancreatic pseudoaneurysm, which developed in a patient with a recent history of acute pancreatitis.     

Intrapancreatic pseudoaneurysm associated with pancreatitis mimicking pancreatic tumor

A 48-year-old man, who had suffered a bout of acute pancreatitis in September 2000, was found in March 2001 to have an increased concentration of serum amylase. A tumor in the pancreas body associated with stenosis and prestenotic dilatation of the main pancreatic duct was detected using imaging techniques. Distal pancreatectomy was performed under the diagnosis of pancreatic carcinoma. An intrapancreatic hematoma due to rupture of a pseudoaneurysm of the intrapancreatic artery was found in the resected specimen. This case illustrates how difficult it is to diagnose a small cancerous tumor in the pancreas and the rare presentation of this intrapancreatic pseudoaneurysm, which developed in a patient with a recent history of acute pancreatitis.     

胰腺结核误诊为胰腺囊腺瘤1例报告

正1病例资料患者男性,42岁,因发热,上腹部疼痛、黄疸1周入院。该患者1周前无明显诱因出现发热,体温38~39℃,以午后、夜间为重,伴上腹部疼痛、黄疸,疼痛呈持续性,向腰背部放散,与饮食无关,腹胀、纳差,无恶心、呕吐,无反酸、腹泻,无咳嗽、咯痰,体质量减轻3 kg。查体:体温39℃、心率102次/min、血压120/70 mm Hg,皮肤、巩膜黄染,腹部平坦,剑突下压痛,无反跳痛及肌紧张,肝     

Disseminated tuberculosis mimicking abdominal metastatic carcinoma: A case report

Rationale:Extra-pulmonary tuberculosis (TB) has long been a diagnostic challenge for clinicians, often requiring extensive workup and invasive procedures, with the risk of significant complications. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a minimally invasive and highly accurate diagnostic modality for the evaluation of mediastinal and abdominal lymphadenopathy and masses. Several reports on the utility of EUS-FNA as a favorable method for diagnosing extrapulmonary TB have been published.Patient concerns:A 54-year-old man complained of intermittent melena.Diagnoses:18 fluorine-fluorodeoxyglucose positron emission tomography/computed tomography revealed suspected carcinoma metastasis. EUS-FNA did not reveal any evidence of malignancy.Interventions and outcomes:Laparoscopy was performed, and frozen section pathology during surgery showed granulomas with focal necrosis. Mycobacterium tuberculosis polymerase chain reaction was positive, but acid-fast bacilli staining was negative. Anti-TB treatment was initiated, and the patient was advised to visit the local TB dispensary regularly.Lessons:The presence of atypical inflammation of inadequate material or non-representative samples of extra-pulmonary TB was observed on EUS-FNA cytology. Mycobacterium tuberculosis polymerase chain reaction and acid fast bacilli should be performed to diagnose TB because of its higher sensitivity.     

Pancreatic tuberculosis

A 63‐year‐old Japanese man visited our institute with fever of unknown origin. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, but a positive tuberculin skin test indicated tuberculosis infection. Negative results for Mycobacterium DNA polymerase chain reaction from sputum and bone‐marrow aspiration biopsy specimens ruled out pulmonary and miliary tuberculosis, respectively. Positron emission tomography (PET) with 2‐[fluorine‐18]‐fluoro‐2‐deoxy‐d ‐glucose (FDG) showed multiple labeled spots within the pancreas body and chest. Distal pancreatectomy was performed with a diagnosis of suspected pancreatic carcinoma, but the histological and microbiological diagnosis was Mycobacterium infection. A rare case of pancreatic tuberculosis evaluated by FDG PET is reported and discussed herein.     

血小板衍化内皮细胞生长因子在胰腺癌组织中的表达及其临床意义

目的:观察血小板衍化内皮细胞生长因子(PD-ECGF)在胰腺癌组织中的表达,探讨其临床意义.方法:利用Elivison免疫组织化学法检测36例手术切除的胰腺癌及21例癌旁正常胰腺组织,以及胃癌、食管癌、肝癌、结肠癌、肺癌及乳腺癌组织各10例中PD-ECGF的表达.分析PD-ECGF与胰腺癌大小、分化程度及淋巴结转移的相关性.结果:PD-ECGF在胰腺癌组织中的表达阳性率显著高于在癌旁正常胰腺组织(88.9% vs 28.6%,P<0.01).PD-ECGF在结肠癌、肝癌、乳腺癌、食管癌、胃癌及肺癌组织中的表达阳性率为60%、70%、80%、90%、90%及80%.Ⅱ-Ⅳ期胰腺癌组织中PD-ECGF的表达阳性率显著高于Ⅰ期胰腺癌组织(100% vs 75%,P<0.05).结论:PD-ECGF为一种非特异性的肿瘤相关因子,其可能与胰腺癌的病程进展有关.     

Colonic tuberculosis mimicking annular carcinoma: Report of a case

Tuberculosis of the colon may be difficult to distinguish from Crohn's diseases or other causes of benign or malignant stricture, but rarely is seen as a classic solitary “apple-core” lesion on barium-enema examination. Such a case is presented, and the radiologic and pathologic features discussed.