This document discusses a case of a 67-year-old man presenting with weight loss, jaundice, and a pancreatic head mass found on imaging. Initial FNA was nondiagnostic. The document then reviews epidemiology, presentations, imaging features, and histology of various solid pancreatic lesions. It discusses evaluating the findings to determine if the mass is neoplastic or non-neoplastic such as autoimmune pancreatitis. EUS with FNA was repeated and found to be consistent with autoimmune pancreatitis, confirmed with elevated IgG4 levels. The patient responded well to steroid treatment.

1. SOLID LESIONS OF PANCREAS
Dr Siddaramu K S, 2nd yr M. Ch. Resident
Discussion: 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 of
Pancreas
 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 of
solid 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 US
Major 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. EUS
Advantages
 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 EUS
Advantages of CECT:
1. Availability – widely used.
2. Resectability ,Distant Mets better tool
3. Vascular Anatomy -3D Reconstruction
4. Low cost
Limitations :
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 Pancreatitis
Similar 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 types
1. Type 1 Involves Adults or elderly
Idiopathic
Secondary to generalized autoimmune process.
2. Type 2 Seen in younger children.

38. AIP
Japanese 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.