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PANCREATIC MASS
Moderator: Dr K.R.PalaniswamySenior consultant,
Dept of Gastroenterology,Apollo Hospitals, Chennai
TNISGCON 2015PANEL DISCUSSION
Panelists
• Dr Anil Arora• Dr G.N.Ramesh• Dr R.Surendran• Dr Rochita• Dr Ashok Parameswaran
History• 47 y, male• Diabetic : 7 yrs
-recent worsening in last 3 months
• Left upper abdominal pain: 6 months-intermittent , each episode lasting for 15 min
• Back pain: 15 days; continuous, moderate• Weight loss -3 kgs in 3 month• No h/o anorexia, vomiting
Examination
• Moderately built• No pallor/ icterus or lymphadenopathy• Abdomen: Soft, non tender. No palpable mass
Questions
• Dr Anil Arora: What are the possibilites?• Dr Ramesh: How will you proceed?
Previous investigations
• CBC-N• LFT,RFT-N• Amylase, Lipase: Normal; CA 19-9: Normal• USG abdomen:
– Ill defined echopoor mass of 27mm in body of pancreas.
– Gallbladder wall thickened with a 5mm polypoid mucosa
CECT ABDOMEN
Questions
• Dr Rochita: Comment on CT abomen
CECT abdomen
• Ill defined hypodense mass lesion 3.9 x 2.3 cms seen in uncinate process with minimal fat stranding
• Another mass in body of pancreas 2.3 x 2.5 cms seen in body of pancreas abutting splenic artery
• Both lesions show contrast enhancement• MPD mildly prominent in body with parenchymal
atrophy in body and distal tail• Small peripancreatic nodes • Imp: Possiblity of pancreatic malignancy to be
considered
Questions
Dr Anil Arora: How to proceed?
Dr Ramesh: Role of EUS in pancreatic malignancy?
Gress et al. GI Endoscopy 1999
EUS diagnostic accuracy
• Staging sensitivity with EUS has consistently been reported to be over 90%.
• EUS is also more accurate in the assessment of vascular invasion that might preclude surgical resection (compared to h-CT/MRI)
Rösch et al. Gastrointest Endosc Clin N Am 1995;5:735-9.Yasuda et al. Endoscopy 1993;25: 151-5.Palazzo et al. Endoscopy 1993;25:143-50.
Brugge et al. GI Endosc 1996;43:561-7.
Pancreatic CancerPancreatic CancerEndoscopic US
Recent evidence suggests that EUS is similar to CT in diagnosis and staging of pancreatic cancer. EUS requires special endoscopic skills and expertise, and it is less readily available worldwide.
A 2.5cm round, hypoechoic tumor is identified in the the
region of the genu. The superior mesenteric vein can be seen separate from the
tumor.
Invasion of the dilated CBD by a large irregular
hypoechoic tumor located in the head of pancreas.
A large hypoechoic tumor is seen to invade the portal vein (arrow), with loss of tumor-vessel interface and tumor extension into vessel lumen.
The dilated CBD contains echogenic sludge.
FNA for solid pancreatic mass• All areas of pancreas including uncinate process and
tail, diameter >5mm• Low complication rate ~ 1-2% (pancreatitis,
haemorrhage)• ? Risk of peritoneal seeding
Sensitivity Sensitivity specificityspecificity PPVPPV NPVNPV
75-93%75-93% 95-100%95-100% 100%100% 25-85%25-85%
Vilmann, Wiresma, Giovannini, Chang, Gress, Bhutani, Hawes, Williams, Palazzo
Suspected pancreatic mass
Ultrasound
H-CT
No MassMass
EUS +/- FNA
Bx (CT, EUS or ERCP)
Palliation (biliary stent/CPN, oncology)
ERCP/Stent
Surgery
Cholangitis OR delayed
resection + jaundice/pruritu
s
Unresectable
Resectable
Unresectable
Resectable
Unresectable
Dr Surendran: Is tissue diagnosis required before surgery?
Surgery
• Laparotomy, locally advanced hard pancreatic mass- uncinate (7cms) and body (5cms) of pancreas, encasing SMA and SMV, hepatic artery and infiltrating serosa of posterior stomach.
• Trial dissection, trucut biopsy of pancreatic tumours and hepatic artery node excision done.
• Laparotomy, trial dissection, trucut biopsy of pancreatic tumours and hepatic artery node excision done
• Dr Surendran’s comments:
Histopathology pictures
HISTOPATHOLOGY
HISTOPATHOLOGY
HISTOPATHOLOGY
HISTOPATHOLOGY
Histopathology
• Pancreatic core biopsies: chronic inflammatory lesion with eosinophilia and dense fibrosis, ductular proliferation and granuloma-no malignancy
• Node- reactive inflammatory changes
• Dr Ashok Parameswaran’s comments:
Dr Rochita: Role of PET-CT in pancreatic malignancy?
Questions
• Dr Anil Arora: What are the possibilities… DD for inflammatory mass of pancreas?
• Dr Ramesh: Can this still be malignant mass? How to proceed?
Two weeks later
• Yellowish discolouration of eyes• Itching• Palpable ill defined mass in epigastrium• Bilirubin: 5mg/dl (Direct: 3.7 mg/dl)• ALP:560 U/L• ALT/AST: 78/60
• Dr Anil Arora: How to proceed?
• Dr Anil Arora: How to proceed?
CECT ABDOMEN
CECT ABDOMEN
Our case Case for comparison
• Dr Rochita’s comments
CECT abdomen• The uncinate process of pancreas is enlarged. However, it
reveals normal enhancement in the venous phase. A similar smaller area is seen in the mid body pancreas. The adjacent main pancreatic duct is narrowed.In the tail and head of pancreas, the main pancreatic duct is dilated. A rim of hypodensity is seen around the lesion in the uncinate process and body of pancreas. Peripancreatic fat planes are hazy
• Few small enhancing peripancreatic nodes are seen.
• The terminal common bile duct is compressed. Proximal to this, the biliary tree is mildly dilated
CECT abdomen• Enhancing soft tissue is seen along side the lesion in
body of pancreas and adherent to the common hepatic artery
• IMPRESSION- CT findings could be suggestive of autoimmune pancreatitis involving uncinate process and body. The soft tissue along the body of pancreas can be post operative changes.– However, the possibility of an atypical neoplasm
cannot be ruled out. A close follow up would be worthwhile.
Questions
• Dr Ramesh: What next? Diagnostic criteria for autoimmune pancreatitis?
HISORt CRITERIA OF AIPCategory CriteriaA. Histology 1. Diagnostic (any one):
a) Pancreatic histology showing periductal lymphoplasmacytic infiltrate with obliterative hlebitis (LPSP) b) Lymphoplasmacytic infiltrate with abundant (>10 cells/hpf) IgG4 positive cells in the pancreas2. Supportive (any one) a) Lymphoplasmacytic infiltrate with abundant (>10 cells/hpf) IgG4 positive cells in involved extra-pancreatic organ b) Lymphoplasmacytic infiltrate with fibrosis in the pancreas
B. Imaging Typical imaging features:1. CT/MR: diffusely enlarged gland with delayed (rim) endhancement2. ERCP: Diffusely irregular, attenuated main pancreatic duct
Atypical Imaging Features: Pancreatitis, focal pancreatic mass, focal pancreatic duct stricture, pancreatic atrophy, pancreatic calcification
C. Serology Elevated serum IgG4 level (normal 8-140 mg/dl)
D. Other Organ involvement
Hilar/intrahepatic biliary strictures, persistent distal biliary stricture, Parotid/lacrimal gland involvement, Mediastinal lymphadenopathy, Retroperitoneal fibrosis
E. Response to steroid therapy
Resolution/marked improvement of pancreatic/extrapancreatic manifestation with steroid therapy
CLINICAL DIAGNOSTIC CRITERIA FOR AIP 2006
1. Diffuse or segmental narrowing of the MPD with irregular wall and diffuse or localized enlargement of the pancreas by imaging studies, such as abdominal US, CT, and magnetic resonance2. High serum γ-globulin, IgG, or IgG4, or the presence of autoantibodies such as antinuclear antibodies and rheumatoid factor3. Marked interlobular fibrosis and prominent infiltration of lymphocytes and plasma cells in the periductal area, occasionally with lymphoid follicles in the pancreas
Diagnosis of AIP is established when criterion 1 and criterion 2 and/or 3 are fulfilled. However, it is necessary to exclude malignant diseases.
AUTOIMMUNE PANCREATITIS
23,0% FOCAL FORM(LIKE MALIGNANT LESION)23,0% FOCAL FORM(LIKE MALIGNANT LESION)
DIFFUSE FORM 77,0%(LIKE ACUTE PANCREATITIS) DIFFUSE FORM 77,0%(LIKE ACUTE PANCREATITIS)
Dr Anil Arora: Sensitivity of Ig G4?
Dr Ashok Parameswaran: Histological criteria for autoimmune
pancreatitis?
Histopathological Features of IgG4-Related Disease-Type I AIP(Predominantly Lobular)
1. Dense lymphoplasmacytic infiltrate
2. Fibrosis, arranged at least focally in a storiform pattern
3. Obliterative phlebitis
Consensus Statement on the Pathology of IgG4-Related Disease Mod Pathol. 2012;25(9):1181-1192
Fibrosis, arranged in a storiform pattern
Dense lymphoplasmacytic infiltrate
Obliterative phlebitis
Histopathological Features of Type II AIP (Predominantly ductal)
• Periductal lymphoplasmacytic infiltrate• Granulocytic epithelial lesion( Neutrophils in
ducts)• Neutrophils within acini
• No storiform fibrosis• No increased IgG4 plasma cells
1.Presence of epithelioid granulomas
2.Prominent neutrophilic infiltrate
Consensus Statement on the Pathology of IgG4-Related Disease
Mod Pathol. 2012;25(9):1181-1192
Histopathological Features Inconsistent With a Diagnosis of IgG4-
Related Disease
Vikram Deshpande, Mari Mino-Kenudson, William Brugge, and Gregory Y. Lauwers (2005) Autoimmune Pancreatitis: More Than Just a Pancreatic Disease?A
Contemporary Review of Its Pathology. Archives of Pathology & Laboratory Medicine: September 2005, Vol. 129, No. 9, pp.
1148-1154.
• Epithelioid cell granulomas have been reported only rarely in association with AIP. However, in a review of 19 pancreatectomy specimens we identified granulomas in 6 cases (32%). In 3 of these cases, granulomas were identified in almost every section examined. In all cases, the granulomas showed an exquisite ductocentric location The lack of nodal involvement and the periductal distribution help exclude pancreatic sarcoidosis and other granulomatous pathologies, including mycobacterial infections.
Types of AIP
AIP TYPE IFeatures of IgG4 disease
Older patients ( 70s)
Serum IgG4 increased
Tissue IgG4 positive plasma cells
AIP TYPE IINo features of IgG4 disease
Younger patients ( 50s)
No Serum IgG4 increase
IgG4 positive plasma cellsnot noted
• IgG4 : Elevated• Started on steroids
Questions• Dr Ramesh: What are the types of autoimmune
pancreatitis?• Dr Rochita: Imaging features differentiating
autoimmune pancreatitis and malignancy.• Dr Surendran: What proportion of Whipple’s surgery
specimen are autoimmune pancreatitis? Indian experience?
• Dr Ashok Parameswaran: Histological findings in other organs involved in IgG4 associated pancreatitis.
• Dr Anil Arora: What proportion of autoimmune pancreatitis respond to steroids? Do they need maintenance treatment? What is the relapse rate?
Types of autoimmune pancreatitis
COMPARISON OF TYPE 1 AND TYPE 2 AIPType 1 AIP Type 2 AIP
Mean age Sixth decade Fourth decade
Gender distribution Predominantly male Equal
Histological pattern Lymphoplasmacytic sclerosing pancreatitis
Duct-destructive pancreatitis
Histological hallmarks Periductal lymphoplasmacytic infiltrateSwirling fibrosisObliterative venulitis
Lymphoplasmacyic infiltrateGranulocyte epithelial lesion with partial/complete duct obstruction
IgG4 cells on immunostaining
Moderate-severe (98%) Moderate (40%) in one study
Serum IgG4 levels Elevated Normal
Other organ involvement Chronic sclerosing sialadenitis, IgG4-associated cholangitis, retroperitoneal fibrosis, IgG4-associated tubulointerstitial nephritis
Inflammatory bowel disease
AIP,autoimmune pancreatitis, IgG4, immunoglobulin G4
CLINICAL PRESENTATIONS OF TYPE 1 AUTOIMMUNE PACREATITIS
Clinical presentations of type I AIP
Pancreatic Predominantly extra-pancreatic
Biliary stricture, sclerosing cholangitis
Interstitial nephritis, renal failure
Retroperitoneal fibrosiswith complications
(e.g., ureteral obstruction)
Acute Post-acute/late
Obstructive jaundice
Pancreatitis
Steatorrhea
Persistent mass
Steatorrhea
Calcification,atrophy
Park, D.H. 2009
Repeat CECT abdomen pictures
• Dr Rochita’s comments:
Follow up
• On review after 4 weeks, significant reduction in size of pancreatic mass; jaundice resolved.
• Repeat CECT abdomen after 3 months, no mass lesion noted.
THANK YOU
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