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Solid lesions of the Pancreas

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  • 1. SOLID LESIONS OF PANCREASDr Siddaramu K S, 2nd yr M. Ch. ResidentDiscussion: Dr Sanjay Nagral; Consultant GI surgeon, Mumbai
  • 2. Case history 67 yr/ M Progressive weight loss( 15 kg/ 6 months) Progressive jaundice No Health related problem in the past, No H/o tobacco in any form, nor alcohol. Exercised daily , Vegetarian .
  • 3.  1st seen by Physician -- found to be healthy and Fit Vitals Stable , Systemic exam Unremarkable. Hb - 13.5, TC - 6,500 , ESR - 13 mm at one hour. Blood sugar was 481mg on fasting state. Diagnosed to have MOD, on Gliclazide 160 mg/d. Week later FBS 116mg and PPBS 174 mg .
  • 4.  Continued to lose weight, slower rate. CBC -No change. Diabetes reasonably well controlled , General examination again unremarkable. Thyroid Function- euthyroid status.
  • 5.  US Abdomen Mass 1.9 * 3.1 cms in head of pancreas, Atrophic pancreas and mildly dilated PD. CBD 9 mm dilated , smooth tapering lower end. LFT - TB 4.3 mg- 70% conjugated, SGPT- 75 i.u ALP -841 I.U. CA 19-9 was 14.5 Chest X-ray was normal.
  • 6.  CECT - similar finding to US. Mass located within the pancreas. Fat plane b/t pancreas and stomach maintained. No involvement of major blood vessels. No metastatic disease detected . Clinical diagnosis -- Pancreatic head mass, most probably neoplasm in back ground of chronic pancreatitis.
  • 7. Hmmmm……… Q: What is your Analysis? What will you do next?
  • 8.  Endoscopic Ultra sonography - carried out . Ill defined mass lesion in the head Pancreas atrophied and slightly hypo- echoic, Mild MPD dilatation ,no stricture or stone . CBD appeared compressed inside the mass but no stone
  • 9.  Mass did not appear to involve major vessels Fat plane between the pancreas and stomach intact.FNA was obtained. Showed inflammatory cells only.
  • 10. What should I do now? Refer to oncosurgeon? Repeat EUS? Review the FNA sample?
  • 11. Evaluating Solid lesions ofPancreas Epidemiology Most common presentations Imaging Serology Histology
  • 12. Solid lesions -Neoplastic Ductal adenocarcinoma( 85-90%) Neuroendocrine tumor (upto 5%) Solid psedopapillary neoplasm (1-2%) Pancreatoblastoma( 0.2%) Lymphoma(0.5%) Metastatic tumors (2-5%) Miscellaneous neoplasms
  • 13. Non Neoplastic Focal Pancreatits, Autoimmune Pancreatitis, ( 5-10%) Lipomatous pseudo hypertrophy(fatty infiltration) Congenital anomalies (Bifid Pancreas, Pancreatic Divisum, Prominent lobulation) Intra pancreatic accessory spleen Miscellaneous: Tuberculosis, Sarcoidosis, Castleman
  • 14. Epidemiology of Solid lesions 1-10 yrs – Pancreatoblastoma,Congenital anomalies. 20-30 yrs -- Solid psedopapillary tumor(F:M 9:1) 30-40 yrs -- Chronic Pancreatitis 50-60 yrs -- NET,Metastasis, Lymphoma More than 60yrs - Ductal Adenocarcinoma, Autoimmune pancreatitis (M:F 2:1)
  • 15. Clinical Presentation ofsolid lesions Nonspecific in Majority Abdominal pain , weight loss,progressive obstructive Jaundice. – PDA Recurrent pain.--CP H/o RCC,Sarcoidosis,TB, Immuno deficiency Symptoms of lymphoma( fever,chills,night sweats)
  • 16. Imaging Trans Abd USG: Accuracy is 50-70%Contrast Enhanced Doppler USMajor limitations of US Detection of small tumors (< 2 cm) Lesions in the left side of the pancreatic gland,
  • 17. After USG what?????EUS or CECT ?
  • 18. EUSAdvantages Detect masses as small as 0.2–0.3 cm. Clarify equivocal findings at CT or MR Allows biopsy of suspect lesions. More sensitive than CT (98% vs 86%) Accurate in local tumor staging (67% vs 47%). Pitfalls It is highly operator dependent Presence of SA calcification, Billroth II,large Hiatus hernia, varices Availability Narrow field of view
  • 19. CECT VS EUSAdvantages of CECT: 1. Availability – widely used. 2. Resectability ,Distant Mets better tool 3. Vascular Anatomy -3D Reconstruction 4. Low costLimitations : 1.Difficulty in small lesions <1-2cm 2.Inflammtory mass- False appearance 3. Radiation. 4.Needle tract seeding (cutaneous & Peritoneal)
  • 20. CECT Abdomen Investigation of choice in Majority(85-97% sensitivity) Dual Phase Multi Detector CT Hypodense , irregular border, Peripancreatic vessel involvement, PDA Double duct sign Upstream MPD Dilatation
  • 21. Adenocarcinoma
  • 22. NET Hypervascular tumor Calcification 20% vs 2% in PDA Vascular infiltration vs Encasement in PDA Less ductal involvement
  • 23. Solid Pseudopapillary Tumor MC in Tail region Tendency to displace rather than invade surrounding structures Rarely causes obstruction of the bile duct or pancreatic duct. Pseudocapsule has low attenuation at CT Internal hemorragic & cystic degeneration
  • 24. Solid Pseudopapillary Tumor
  • 25. Lymphoma More CBD Dilatation than MPD Enlarged lymph nodes below Renal vein Invasive; No respect of Anatomic boundaries Vascular invasion less common
  • 26. Metastasis Most common from Renal Cell Carcinoma, Ca Lung, Ca Breast, CRC Hypervascular Mets--- Renal Cell Carcinoma Hypovascular Mets--- lung ,Breast, Colon Equivocal cases Require Biopsy.
  • 27. RCC Mets
  • 28. Focal PancreatitisSimilar to Adenocarcinoma Hypo-attenuating Double Duct Sign Duct Stricture, Infiltration of fat, Vessels Duct Penetrating Sign PD irregularity Focal Pancreatitis Pancreatic Calcification.
  • 29. MRI in solid lesions Fatty infiltration of pancreas & SPT- Inv of Choice Mangafodipir Trisodium enhanced MRI –PDA Better for local extent,vascular involvement than for Lymph node Not Superior to CECT in other lesions.
  • 30. FDG-PET Preoperatively suspected distant metastasis. Differentiate benign vs malignant Investigate the response to neoadjuvant Rx Currently not a Preop Diagnostic Standard.
  • 31. Role of ERCP ? Double duct sign in Adenocarcinoma, focal Pancreatitis Biopsy & Brush Cytology- (less sensitive) Pre op Biliary Stenting
  • 32. SEROLOGY: CA 19-9 Most commonly valued marker (0-37 u/ml) Not specific, high levels seen in benign disease Normalization after resection improved outcome Rising level after resection is a marker of relapse Levels > 1500 correlate with unresectable tumors Not cost effective for screening
  • 33. Serology Raised Ig G4, ANA Anti smooth muscle, Antihuman lactoferrin Functional Pan NET – Glucagon, Gastrin,VIP…. Pancreatic Lipase – Acinar Cell Ca CEA,CA 242,CA 72-4.-PDA
  • 34. Histology Difficult to differentiate b/t Ca and CP More stroma and less of cells Small nests, scattered, round ,well delineated units in exocrine back ground (NET) Lymphoplasmacytic infiltration in AIP
  • 35. Coming back to our patient… IgG-4, grossly elevated Final diagnosis- Autoimmune pancreatitis, with focal inflammatory Mass lesion. Patient was put on 30 mg of prednisolone At 4 wks of Rx, the Mass disappeared.
  • 36. ERCP
  • 37. AIP Classification: Two types1. Type 1 Involves Adults or elderly IdiopathicSecondary to generalized autoimmune process.2. Type 2 Seen in younger children.
  • 38. AIPJapanese Pancreas Society diagnostic criteria(2002) I. Imaging studies show diffuse narrowing of MPD with irregular wall (>1/3 of length ). II. Lab -abnormally elevated level ( IgG4), or the presence of Auto Antibodies III. Histology shows fibrotic changes with lymphocyte and plasma cell infiltrate. For diagnosis, criterion I must be present with criterion II and/or III .
  • 39. Take Home Message Accurate diagnosis can be challenging Multimodality imaging approach needed Not all Solid lesions are Malignant Knowledge of relevant clinical information Key radiologic features & Histology Helpful.
  • 40. References Multimodality Imaging of and Non neoplastic Solid lesionsof the pancreas, Radiographics journal,RSNA,2011. 993-1013 Winter JM, Cameron JL, Lillemoe KD, et al. Periampullary and pancreatic incidentaloma: a single institution’s experience with an increasingly common diagnosis. Ann Surg 2006;243(5):673–680; discussion 680–683. Ros PR, Mortelé KJ. Imaging features of pancreatic neoplasms. JBR-BTR 2001;84(6):239–249. Blumgart’s Surgery of the liver,biliary tract,and Pancreas.