Differential Diagnosis Of Pancreatic Masses Research Articles

Pancreatic endometriosis: a systematic review.

Extrapelvic manifestations of endometriosis can be identified in nearly every part of the female body, and the true prevalence of extrapelvic locations is unknown. Pancreatic endometriosis may manifest in several ways, ranging from emergency presentations to asymptomatic cysts. A systematic PubMed and Scopus search was conducted. Eighteen patients from 17 case reports were included. The patients' mean age was 39.3 (range: 21-72) years. An emergency presentation was noted in 8 of the 18 (44.4%) patients. Menstrual irregularity was present in 3 (16.7%) patients, while in 3 (16.7%) cases there was simultaneous presence of endometriosis elsewhere. The most frequent symptoms at presentation of pancreatic endometrial cysts were epigastric pain, acute left upper quadrant pain, back pain, nausea/vomiting/diarrhea, which occurred in 12 (66.7%), 11 (61.1%), 4 (22.2%), and 6 (33.3%) patients, respectively. Only one case presented as an asymptomatic pancreatic cyst. The maximum diameter of the endometrial cysts ranged from 1-16 cm. In the majority of cases, surgical treatment was offered (16/18, 88.9%). Recurrence of pancreatic endometrial cyst occurred in one case only, following needle aspiration of the endometrial cyst. No fatality was reported. Review of the available published literature suggests that pancreatic endometriosis is a rare condition that should be included in the differential diagnosis of pancreatic masses. Further clinical and experimental studies are necessary to investigate the pathogenesis of extrapelvic and pancreatic endometriosis.

A Rare Case of Pancreatic Actinomyces

Actinomyces israelii is a filamentous, gram-positive anaerobic bacterium commonly found in the upper gastrointestinal tract, colon, and female genital tract. Rarely, actinomycosis can infect the pancreas most commonly after pancreatic instrumentation, often mimicking malignancy. We describe a case of a 26-year-old woman who presented with epigastric abdominal pain and nausea without prior pancreatic instrumentation. Abdominal imaging demonstrated a mass in the pancreatic head with fine-needle biopsy revealing Actinomyces. The patient was successfully treated with long-term antibiotic therapy resulting in resolution of the mass. Our case emphasizes the importance of considering nonmalignant etiologies in the differential diagnosis of pancreatic masses.

S1686 Primary Pancreatic Diffuse Large B Cell Lymphoma: A Rare and TreaTable Malignancy

Introduction: Pancreatic lymphoma comprise less than 1 % of pancreatic malignancies. Most common location of diffuse large B cell lymphoma (DLBCL) are lymph nodes. Clinical symptoms and imaging studies have significant similarity resulting in delayed diagnosis or early initiation of comfort care measures. It is important to determine the histology of pancreatic tumor given the differences in management and prognosis. Here we report a rare case of primary DLBCL arising from pancreas. Case Description/Methods: 62-year-old female with history of HTN and DM presented with 30 lbs unintentional weight loss epigastric abdominal pain and early satiety. CT abdomen with IV and oral contrast demonstrated pancreatic mass. Core biopsy of pancreatic head mass demonstrated infiltration by large atypical lymphoid cells with high N/C ratio, round nuclear contour, fine chromatin and variably prominent nucleoli (Figure A). Atypical mitosis and apoptosis seen in background. Lymphoma cells positive for CD 19, CD 20 (Figure B). Final diagnosis Large B cell lymphoma germinal center type. FISH for BCL 2, C MYC were normal ruling out possibility of double or triple hit lymphoma. Cancer antigen 19-9 at the time of diagnosis was within normal limits. FDG PET/CT prior to initiation of treatment showed main foci of increased tracer activity appears to be in the proximal body of the pancreas just medial to the stomach, measures greater than 4 cm in diameter, and has a maximum SUV of 11.86 (Figure C). Rituximab- Cyclophosphamide HydrOxyadriamycin Prednisone (R-CHOP) every 3 weeks initiated. After one cycle of R-CHOP reported significant improvement in epigastric pain and started gaining weight. She completed 6 cycles of R-CHOP. Post treatment FDG PET/CT complete resolution of upper abdominal lymph node mass (Figure D). She remains in remission for the past 1 year. Discussion: Our case is an example of successful biopsy and treatment with aim to cure pancreatic malignancy. Despite radiological differences between pancreas adenocarcinoma and lymphoma, it is crucial to obtain adequate tissue sampling during from pancreas to establish histological diagnosis prior to discussion of prognosis and treatment plan. In general, DLBCL germinal center type has a 5-year survival of 70% with R-CHOP. Differential diagnosis of pancreatic mass that confer better prognosis than adenocarcinoma include neuroendocrine tumor, solid pseudopapillary tumor and lymphoma. Therefore, it is important to obtain biopsy and direct therapy based on histology.Figure 1.: A: Core biopsy of pancreatic head mass demonstrated infiltration by large atypical lymphoid cells with high N/C ratio, round nuclear contour, fine chromatin and variably prominent nucleoli. B: Lymphoma cells positive for CD 19, CD 20. C: FDG PET/CT prior to initiation of treatment showed main foci of increased tracer activity appears to be in the proximal body of the pancreas just medial to the stomach, measures greater than 4 cm in diameter, and has a maximum SUV of 11.86. D: Post treatment FDG PET/CT complete resolution of upper abdominal lymph node mass.

Artificial intelligence using deep learning analysis of endoscopic ultrasonography images for the differential diagnosis of pancreatic masses.

BACKGROUND : There are several types of pancreatic mass, so it is important to distinguish between them before treatment. Artificial intelligence (AI) is a mathematical technique that automates learning and recognition of data patterns. This study aimed to investigate the efficacy of our AI model using endoscopic ultrasonography (EUS) images of multiple types of pancreatic mass (pancreatic ductal adenocarcinoma [PDAC], pancreatic adenosquamous carcinoma [PASC], acinar cell carcinoma [ACC], metastatic pancreatic tumor [MPT], neuroendocrine carcinoma [NEC], neuroendocrine tumor [NET], solid pseudopapillary neoplasm [SPN], chronic pancreatitis, and autoimmune pancreatitis [AIP]). METHODS : Patients who underwent EUS were included in this retrospective study. The included patients were divided into training, validation, and test cohorts. Using these cohorts, an AI model that can distinguish pancreatic carcinomas from noncarcinomatous pancreatic lesions was developed using a deep-learning architecture and the diagnostic performance of the AI model was evaluated. RESULTS : 22 000 images were generated from 933 patients. The area under the curve, sensitivity, specificity, and accuracy (95 %CI) of the AI model for the diagnosis of pancreatic carcinomas in the test cohort were 0.90 (0.84-0.97), 0.94 (0.88-0.98), 0.82 (0.68-0.92), and 0.91 (0.85-0.95), respectively. The per-category sensitivities (95 %CI) of each disease were PDAC 0.96 (0.90-0.99), PASC 1.00 (0.05-1.00), ACC 1.00 (0.22-1.00), MPT 0.33 (0.01-0.91), NEC 1.00 (0.22-1.00), NET 0.93 (0.66-1.00), SPN 1.00 (0.22-1.00), chronic pancreatitis 0.78 (0.52-0.94), and AIP 0.73 (0.39-0.94). CONCLUSIONS : Our developed AI model can distinguish pancreatic carcinomas from noncarcinomatous pancreatic lesions, but external validation is needed.

AB154. SOH22ABS135. Laparoscopic distal pancreatectomy and splenectomy for an intrapancreatic accessory spleen—a case report and review of the literature

Background: This case serves as a reminder to consider ectopic splenic tissue in the differential diagnosis of pancreatic masses. The literature shows a lack of awareness and overtreatment of this condition due to clinical and radiologic concern for malignancy, namely neuroendocrine tumours, metastases.

Pull vs. wet: rendimiento diagnóstico y calidad de las muestras de las PAAF guiadas por USE en las masas sólidas del páncreas

Differential diagnosis of pancreatic masses is challenging. The endoscopic ultrasound-guided fine-needle aspiration method with the highest diagnostic yield has not been established. It was realized a prospective, randomized, double-blind study of the endoscopic ultrasound-guided fine-needle aspiration in solid lesions of the pancreas to compare and evaluate diagnostic yield and aspirate quality between wet and pull technique. Forty-one patients were enrolled. The wet technique presented a sensitivity, a specificity, a positive and negative predictive value, and a diagnostic accuracy of 58.3%, 100%, 100%, 25% and 63.4%, respectively. In the capillary technique they were: 75%, 100%, 100%, 35.7% and 78.1%, respectively. Comparing the diagnostic yield between both techniques, there was no statistically significant difference (McNemar’s test p = 0.388). Regarding the cellularity of the specimen, both in cytology and the cell block samples, no significant difference was observed between the techniques (p = 0.84 and 0.61, respectively). With respect to contaminating blood in the specimen, there was no difference in cytology samples (p = 0.89) and no difference in cell block samples (p = 0.08). The suitability of cytology samples for diagnosis was similar in both techniques (wet = 57.5% and capillary = 56.7%, p = 0.94) and there was no difference in cell block samples (wet = 75% and capillary = 66.1%, p = 0.38). In this study we did not observe differences in diagnostic yield or sample quality. Since both techniques are effective, we suggest the simultaneous and alternate use of both methods.

Groove pancreatitis: a case report with a brief review of this diagnostic challenge.

Groove Pancreatitis is an uncommon and still under-recognized form of recurrent or chronic pancreatitis that involves the space between the pancreatic head, the duodenum and the common bile duct, the so called groove area. Its importance is that it can mimic pancreatic carcinoma, it may coexist with it or even masks it and should be considered in the differential diagnosis of pancreatic masses or duodenal stenosis. Groove Pancreatitis represents a diagnostic challenge because, from a clinical point of view, its manifestations and complications can be numerous and different from each other. Despite modern imaging techniques, even in the most specialized centers, many untrained radiologists and gastroenterologists may encounter difficulty to make the proper diagnosis. In this work, we have described a case Groove Pancreatitis manifesting as flare up of previously diagnosed chronic pancreatitis and we have tried to make a brief revision of literature concerning diagnosis and treatment of the disease.

Telomerase activity in the differential diagnosis of pancreatic mass.

In this manuscript, we show that the detection of telomerase activity in pancreatic mass tissue provides early evidence of a cancerous process that requires a well-timed surgical treatment. Eighty-eight patients with pancreatic mass (both benign and malignant) were involved in the research. Comparative analyses of the data and instrumental methods to define the histological structure of tumor mass and measure telomerase activity have been carried out. Intense telomerase activity (+++) in the tissue of pancreatic mass determines cancer with high accuracy. One hundred percent of patients with pancreatic cancer had high telomerase activity. In 32.4% of patients with average telomerase activity (++) pancreatic cancer was diagnosed. The average telomerase activity (++) in pancreatic tumors gives an early indication of pancreatic cancer and requires dynamic observation for 6 to 12 months (P<0.05). Low telomerase activity (+) in patients with benign tumors is an accurate sign for confirming a diagnosis. The detection of telomerase activity in pancreatic mass tissue provides early evidence of a cancerous process that requires a well-timed surgical treatment.

Contrast‑enhanced harmonic endoscopic ultrasonography for the differential diagnosis of pancreatic masses: A systematic review and meta‑analysis

Understanding the difference between malignant and benign pancreatic masses is critical in terms of diagnosis, although this is difficult to determine in clinical practice. The contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) technique was introduced in 2010, although, to the best of the authors' knowledge, there has been no systematic review or meta-analysis to date evaluating its diagnostic performance for the differentiation of pancreatic masses. The aim of the present study was to systematically evaluate the diagnostic performance of CH-EUS for the differentiation of pancreatic masses. Search key words and inclusion and exclusion criteria were initially presented. Two independent authors read and extracted the relevant information from the included studies. Disagreements were resolved through discussion with another two experienced authors. Metadisc and Stata software were used for the meta-analysis and the evaluation of bias. A total of 16 studies comprising 1,325 patients were included in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of CH-EUS were used to distinguish between malignant and benign tumors, and the values obtained were 93% [95% confidence interval (CI): 91-94%], 84% (95% CI: 80-87%), 5.58 (95% CI: 3.90-7.97), 0.09 (95% CI: 0.07-0.11) and 72.56 (95% CI: 48.93-107.60), respectively. The area under the summary receiver operating characteristic curve was determined to be 0.96. No publication bias was identified in this meta-analysis. Taken together, these results confirm that CH-EUS has a high accuracy rate for distinguishing between benign and malignant pancreatic space-occupying lesions, and it may therefore be used as an effective diagnostic tool for pancreatic masses.

Contrast-Enhanced EUS for Differential Diagnosis of Pancreatic Masses: A Meta-Analysis.

Background Though methods for the diagnosis of pancreatic masses are various, such as ultrasonography (US), computed tomography (CT), endoscopic ultrasonography (EUS), and contrast-enhanced computed tomography (CE-CT), their sensitivity, specificity, and accuracy are not quite satisfying. Contrast-enhanced endoscopic ultrasonography (CE-EUS), as a new technique, has its own unique advantages in diagnosing pancreatic disease. However, its sensitivity, specificity, and accuracy are still controversial. Objective To evaluate the accuracy of CE-EUS for differential diagnosis between benign and malignant pancreatic mass lesions. Design Eighteen relevant articles systemically searched from PubMed, Web of Science, Ovid, Scopus, and MEDLINE were selected. The pooled results were calculated in a fixed effects model. Main Outcome Measurement The pooled sensitivity, specificity, positive likelihood ratio (LR), negative likelihood ratio, diagnostic odds ratio (OR), and summary receiver operating characteristic (SROC) curve. Results The pooled sensitivity, specificity, and diagnostic odds ratio of CE-EUS for the differential diagnosis of pancreatic adenocarcinomas were 0.91 (95% confidence interval (CI), 0.89-0.93), 0.86 (95% CI, 0.83-0.89), and 69.50 (95% CI, 48.89-98.80), respectively. The SROC area under the curve was 0.9545. The subgroup analysis based on excluding the outliers showed that the heterogeneity was eliminated and the pooled sensitivity and specificity were 0.92 (95% CI, 0.90-0.93) and 0.87 (95% CI, 0.84-0.89), respectively. The SROC area under the curve was 0.9569. Conclusion CE-EUS is a useful method to distinguish pancreatic adenocarcinoma from other pancreatic diseases. Compared with EUS elastography, it has higher specificity. However, it is still not superior to pathological diagnosis for the identification of pancreatic carcinomas.

The importance of pancreatic inflammation in endosonographic diagnostics of solid pancreatic masses

Endosonography (EUS) is one of the main diagnostic tools for the differential diagnosis of pancreatic masses. Theaim of our study was to describe the value of this technique in the work-up of solid pancreatic lesions, considering the influenceof the morphological evidence of pancreatic inflammation in the diagnostic process. Retrospectiveanalysis of prospectively collected data in our tertiary University center. From March 2007 to October 2015, 218 patientsunderwent EUS for a suspected solid pancreatic neoplasm (based on previous cross-sectional imaging results, idiopatic acutepancreatitis, weight loss, pancreatic hyperenzymemia, painless jaundice or elevated Ca 19-9 values). Malignantlesions were diagnosed in 98 (45%) patients. Sensitivity of EUS for malignancy was 91% and specificity 89.2%. Signs ofpancreatic inflammation in the surrounding pancreatic parenchyma around the focal lesion were present in 97 patients (44.4%)(more often in men, smokers and drinkers, and the most common etiology was focal chronic pancreatitis) and in these patientsthe sensitivity and sensibility dropped to 44% and 87.1%, respectively. In patients without signs of pancreatic inflammation,the pancreatic focal lesions were adenocarcinoma, neuroendocrine tumor, ventral/dorsal split, non-pancreatic pathology, pancreaticlipomatosis and autoimmune pancreatitis. Pancreatic inflammation (either focal or involving the wholegland) lowers the diagnostic sensibility of EUS in the work- up of pancreatic masses suspected for cancer, requiring furtherinvasive diagnostic methods. Focal autoimmune pancreatitis and paraduodenal pancreatitis are still confused with pancreaticcancer, even in the absence of pancreatic inflammation.

A meta-analysis of contrast-enhanced harmonic endoscopic ultrasonography on differential diagnosis of pancreatic mass

Objective To estimate the value of contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) on differential diagnosis of pancreatic mass. Methods Multiple Chinese and English databases were retrieved to selected relevant literature. The quality of literature was assessed, and the data were meta-analyzed using Metadisc 1.4 and STATA 14.0 software. Results A total of 16 researches with 1 352 patients were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio was 93% (95%CI: 92%-95%), 84% (95%CI: 80%-87%), 5.82 (95%CI: 4.06-8.33), 0.08 (95%CI: 0.06-0.10), and 77.33 (95%CI: 52.37-114.17), respectively. The area under the summary receiver operating characteristic curve was 0.96 (95%CI: 0.94-0.97). The results of subgroup analysis demonstrated that the number of cases, region, QUADAS scores, the diameter and type of mass, and the experience of diagnostician were not the source of heterogeneity. After 2 articles with larger bias were eliminated, the heterogeneity dropped to an acceptable range, and the pooled sensitivity, specificity, positive predictive value and negative predictive value had no significant change. All these suggested that the results of meta-analysis were reliable. Conclusion CEH-EUS has a high accuracy in differential diagnosis of pancreatic mass, and can be used as an effective diagnostic method. Key words: Endoscopic ultrasonography; Contrast-enhanced harmonic; Pancreatic neoplasms; Diagnosis; Meta-analysis

Pancreatic tuberculosis causing biliary obstruction and mimicking pancreatic malignancy

Tuberculosis (TB) is a bacterial infection which can affect any part of the body from head to toe and has various presentations depending on the site of the infection. Pancreatic TB is very rare and usually happens as a part of disseminated or miliary TB, whereas isolated pancreatic TB is even rarer. Here, we present a case of pancreatic TB at a TB endemic zone which presented with obstructive jaundice and pancreatic lesions mimicking pancreatic malignancy. A 46-year-old Saudi female patient presented with right upper quadrant abdominal pain associated with dark coloured urine and pale stool. The patient had been admitted to the surgical ward as a case of acute cholecystitis for further evaluation. On abdominal ultrasound (US), findings demonstrated dilated common bile duct (CBD), but the distal part was difficult to be visualised; hence, further evaluation by magnetic resonance cholangiopancreatography (MRCP) was recommended to look for CBD stones. The MRCP showed two focal pancreatic lesions causing the distal CBD obstruction with no stones at CBD. Based on these findings, malignancy was considered and computed tomography-guided fine-needle aspiration biopsy from the pancreatic neck lesion was performed. This demonstrated multiple granulomas and lymphocytes with no malignant cell which indicated pancreatic TB. The patient became well after a course of anti-TB medications. pancreatic TB should be included in the differential diagnosis of pancreatic masses, especially in those patients who live in an endemic area of TB. A biopsy is necessary to establish the diagnosis and start the appropriate treatment for this curable disease as soon as possible.

Su1369 A New Model Construted by Logistic Regression of Eus-Elastography for the Differential Diagnosis of Pancreatic Masses: A Two-Step Prospective Study in 115 Patients

Su1369 A New Model Construted by Logistic Regression of Eus-Elastography for the Differential Diagnosis of Pancreatic Masses: A Two-Step Prospective Study in 115 Patients

New diagnostic techniques for the differential diagnosis of pancreatic mass: Elastography helps me 100.

New diagnostic techniques for the differential diagnosis of pancreatic mass: Elastography helps me 100.

Pancreatic Involvement of Burkitt Lymphoma in a Child and Review of the Literature

Pancreatic involvement of non-Hodgkin lymphoma is extremely rare in childhood and can be overlooked in differential diagnosis of pancreatic masses. In this report we describe a 10-year-old boy who presented with pancreatitis and obstructive jaundice, which was the result of pancreatic involvement of Burkitt lymphoma.

Primary pancreatic lymphoma: A rare cause of pancreatic mass.

Primary pancreatic lymphoma (PPL) is a rare entity, most likely to be clinically misdiagnosed as pancreatic cancer. The cure rate of PPL is higher compared with that of pancreatic adenocarcinoma. This is the case report of a 57-year-old male patient who was hospitalized with complaints of abdominal pain, weight loss and jaundice. The radiological evaluation revealed a pancreatic head mass and, following endoscopic ultrasound-guided fine-needle aspiration biopsy, the tumor was diagnosed as diffuse large B-cell lymphoma. The final diagnosis was PPL, and the patient went into remission after receiving three cycles of treatment with rituximab, doxorubicin, cyclophosphamide, vincristine and prednisolone (R-CHOP regimen). Therefore, PPL should be considered in the differential diagnosis of pancreatic masses and its management differs from that of other types of pancreatic tumor.

The Challenging Diagnosis of Pancreatic Masses: Not All Tumors Are Cancers

In the elderly patients, where biopsy-induced complications could outweigh the benefit, the identification of pancreatic masses is generally referred to as a synonymous of pancreatic cancer and patients are dismissed with no further options than palliative and supportive care. Notwithstanding, not all pancreatic tumors are cancers and therefore alternative diagnoses need to be investigated, especially when patients are unfit for invasive diagnostic procedures. Here, we report a case of an aged patient that was admitted to an internal medicine division for a previously diagnosed pancreatic cancer. The reassessment of the diagnosis has allowed identifying the pancreatic mass as a manifestation of focal pancreatitis in the context of an IgG4-related disease. Accordingly, patient was treated with steroids with rapid clinical improvement. This clinical case suggests that autoimmune diseases should always be considered in the differential diagnosis of pancreatic masses of the elderly.

Mo1528 Role of Contrast Harmonic Endoscopic Ultrasonography (Ch-EUS) in the Characterization of Pancreatic Metastases

Pancreatic metastases account for 2-5 % of all pancreatic malignancies and challenge differential diagnosis versus primary pancreatic neoplasia. EUS fine needle aspiration (FNA) shows the greatest accuracy in the differential diagnosis of pancreatic masses. However, EUS-FNA may suffer from suboptimal sensitivity and low but not negligible rate of complications. Recently, CH-EUS has been reported as an useful adjunct in differential diagnosis of pancreatic tumors. Our aim was to evaluate the potential role of CH-EUS in the differential diagnosis of pancreatic metastases.

Endoscopic Ultrasound Elastography for Differential Diagnosis of Pancreatic Masses: A Meta-Analysis

Distinguishing malignant from benign pancreatic tumors is challenging with current imaging techniques. Endoscopic ultrasound (EUS) elastography has further improved the efficacy of EUS for characterizing pancreatic lesions. To assess, by combining data from existing trials, the accuracy of EUS elastography in diagnosing malignant tumors for patients with pancreatic masses. All relevant studies published were identified by systematic searching of databases. A meta-analysis was performed using a random-effects model to combine study results. Seven studies involving 752 patients were included. The sensitivity of EUS elastography for differential diagnosis of solid pancreatic masses was 97 % (95 % CI, 0.95-0.98), and the specificity was 76 % (95 % CI, 0.69-0.82). The area under the curve under summary receiver operating characteristic (SROC) was 0.9529. The combined positive likelihood ratio was 3.71 (95 % CI, 2.72-5.07), and the negative likelihood ratio was 0.05 (95 % CI, 0.02-0.13). Our meta-analysis shows that EUS elastography is a useful tool for differential diagnosis of solid pancreatic neoplasms with very high sensitivity and relatively low specificity. The results indicate that EUS elastography not only provides information complementary to that from EUS but also potentially increases the yield of fine needle aspiration and reduces the number of unnecessary biopsies.