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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
CYSTIC TUMOR OF THE PANCREASM Vix, MD, R Ceulemans, MD, D Mutter, MD, PhD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Summary The management of cystic tumors of the pancreas depend on their nature. The differential diagnosis of such tumors relies on a body of evidence including imaging studies, and analysis of the intracystic fluid. Indeed, if pseudocysts and serous cystadenomas may benefit from a mere monitoring, mucinous cystadenomas and cystadenocarcinomas should benefit from total surgical resection so that recovery is complete. 2. KeywordsPancreas, serous cystadenoma, mucinous cystadenoma, cystadenocarcinoma 3. Patient35-year-old female 4. Past medical historyNone 5. History of present illnessThe patient consulted a physician for abdominal mass. This mass was palpable, yet there was no other clinical sign. 6. Examinations6.1. Biological findingsNormal biological findings (especially, normal findings on liver function tests and normal pancreatic findings)Blood chemistries:
6.2. UltrasonographyUltrasonography showed a partially subhepatic cystic mass.6.3. CT scanCT scan showed a gallbladder without stones. Enlargement of the corporeo-caudal part of the pancreas was found. There was no contrast uptake within the cysts. No sign of concomitant pancreatitis nor infiltration into the peripancreatic fat were observed.No peripancreatic adenopathies nor any abnormality in the liver parenchyma were noted. 6.4. Cyst fluid aspirationCharacter of the fluid:The fluid had a serous quality. Assay of intracystic markers:
Pathological exam of the fluid: The fluid was serous and showed no trace of cellular elements. 7. TreatmentDifferent arguments indicated a benign cystic tumor of the pancreas. The patient did not undergo any intervention. Clinical monitoring was maintained. 8. DiscussionThe main objective raised by the discovery of the pancreatic lesion was to firmly establish the diagnosis and exclude malignancy. Diagnosis was based on a body of clinical, radiological, biological and anatomopathological evidence. If the features of the imaging studies made it possible to guide diagnosis, cyst fluid aspiration and anatomopathological examination of the cyst and the intracystic fluid determined their actual nature. Analysis of the fluid made it possible to detect whether or not cell elements were present, assay tumoral markers (CEA level: 19-9, CA 72-4 assay), pancreatic enzymes, and evaluate the cyst fluid viscosity. A number of potential differential diagnoses may be evocated:
9. Diagnosis9.1. Pseudocyst of the pancreasThe diagnosis of pseudocyst is usually easy to establish.
9.2. Serous cystadenomaA serous cystadenoma is usually classified as microcystic even though several groups of macrocysts may be observed. Imaging studies show an alveolar structure characteristic of a beehive. A fibrotic calcified stroma with a central stellar scar is often found.Ultrasonography shows a solid homogeneous tumor. CT scan shows an areolar structure of microcystic regions. It helps identify a central fibrotic tract and stellar calcifications. The workup may be completed with arteriography, magnetic resonance imaging study or endoscopic retrograde cholangiopancreatography (ERCP). However, they do not permit establishing a firm diagnosis. 9.3. Mucinous cystadenomaMucinous tumors are represented by mucinous cystadenomas and cystadenocarcinomas.The cysts present a density resembling that of water on CT scan. Intracystic vegetations whose size is proportional to the degenerative process are usually observed. Malignancy is established in the presence of metastases. Arteriography usually shows a hypervascularized tumor. ERCP shows a retraction of adjacent structures and possible relationships with the cyst. 9.4. CystadenocarcinomaDiagnosis of a malignant condition (cystadenocarcinoma) is usually easy to establish. Elements indicating a cystadenocarcinoma are elevated serum CA 19-9 values greater than 100 U/mL. Yet, a firmly established diagnosis is achieved through cyst fluid aspiration. Regarding mucinous tumors, a concomitant elevation of serum CA 19-9 and CA 72-4 values has also a 95% sensitivity. CEA assay is also sensitive with a threshold level of 500 ng/mL. Above a rate of 500 ng/mL, the tumor is likely to be mucinous rather than serous. The marker which may also be suited is CA 72-4. However, cytology only is 100% specific when it is positive.Other experts have suggested that a tissue antigen be assayed (tissue polypeptide antigen 900,000 units per mL for cholangiocarcinoma, 16,000 units per mL for benign cystadenomas). The introduction of PET scan may modify the diagnostic approach of such tumors. In the presence of uncertain diagnosis or mucinous cystadenoma, surgical resection is imperative. 9.5. Ductal ectasiaDuctal ectasia is most clearly identified during ERCP. It is characterized by a deformation of the pancreatic duct.10. ConclusionsDiagnostic features allowed us to exclude malignancy in this cystic tumor of the pancreas. 11. References
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