Differential Diagnosis Of Pancreatic Tumors Research Articles

Frantz tumor: Case reports

Introduction: Frantz tumor or Solid Pseudopapillary Neoplasm are rare neoplasms that represent between 0.2-2.7% of exocrine pancreatic neoplasms. It was first described by Virginia K. Frantz in 1959, but it was included in the World Health Organization (WHO) classification of pancreatic tumors in 1996 as a “pseudopapillary tumor” of the pancreas. Of unknown etiology, its incidence is observed in young women; Clinically it manifests with slow growth of a solid abdominal mass accompanied or not by abdominal pain. There has been a gradual increase in the incidence of this tumor in the last two decades, probably due to the greater frequency of the use of cross-sectional images in the evaluation of abdominal symptoms. Its degree of malignancy is low and complete resection allows the patient a favorable evolution and prognosis.Materials and Methods: A retrospective observational bibliography review of patients with PNS operated on from October 2016 to December 2022 was carried out.Results: The patients operated on for Frantz tumor analyzed in the study did not have recurrences and/or metastases.Conclusion: pseudopapillary neoplasia of the pancreas (Frantz's tumor) should be considered in the differential diagnosis of pancreatic tumors, especially in young women, since surgical treatment has a good prognosis even if the tumors are large

Efficacy of Contrast-Enhanced Endoscopic Ultrasonography for the Diagnosis of Pancreatic Tumors

Endoscopic ultrasound can be useful for obtaining detailed diagnostic images for pancreatic disease. Contrast-enhanced harmonic endoscopic ultrasound has allowed to demonstrate not only microvasculature but also real perfusion imaging using second-generation contrast agents. Furthermore, endoscopic ultrasound fine-needle aspiration cytology and histology have become more ubiquitous; however, the risk of dissemination caused by paracentesis has yet to be resolved, and the application of less invasive contrast-enhanced endoscopic ultrasound for the differential diagnosis of pancreatic tumors has been anticipated. Contrast-enhanced harmonic endoscopic ultrasound can contribute to the differential diagnosis of pancreatic tumors.

Time intensity enhancement patterns of solid pancreatic tumors with the use of contrast-enhanced harmonic endoscopic ultrasonography

Background and Objectives:Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) was reported as a useful tool for differential diagnosis of pancreatic tumor. However, the time to evaluate the intensity of enhancement is still uncertain. The aim of this study was to evaluate the vascularization patterns of solid pancreatic tumors.Methods:A total 46 patients who underwent CH-EUS for solid pancreatic tumors (pancreatic adenocarcinoma [PDAC] 33, pancreatic neuroendocrine tumor [PNET] 8, autoimmune pancreatitis [AIP] 5) were retrospectively analyzed. We examined maximum/minimum intensity (Max-I/Min-I), time to peak intensity (TTP), and time to start washout (TTW) of the lesions.Results:Max-I of CH-EUS showed isoenhancement pattern in 21 cases (64%) of PDAC and five cases (100%) of AIP. On the other hand, Max-I of NET showed hyperenhancement pattern in six cases (75%). Min-I of CH-EUS showed hypoenhancement pattern in 23 cases (70%) of PDAC, four cases (80%) of AIP, and five cases (63%) of NET. Median TTP of each solid pancreatic tumor was PDAC (22 s), AIP (20 s), and NET (17 s). Median TTW for PDAC was 38 s, AIP 45 s, and NET 33 s.Conclusions:TTP/TTW was different depending on each tumor. Further study is warranted to clarify the time intensity patterns.

Perivascular epithelial cell tumor (PEComa) of the pancreas: a case report and review of previous literatures.

Perivascular epithelial cell tumors (PEComas), firstly described by Bonetti in 1992, are a family of mesenchymal tumor composed of perivascular epithelioid cells having epithelioid or spindle morphology and exhibiting melanocytic and myogenic immunoreactivities. We herein described a 61-year-old woman who presented with epigastric pain. Preoperative imaging studies showed that 7-cm-sized mass was located in pancreatic head and body, and pancreaticoduodenectomy was performed. Histological findings showed that the tumor was composed of clear epithelioid cells with abundant glycogen granules, which grew in a nested and alveolar pattern around blood vessels. The tumor cells showed immunoreactivities for HMB-45 but did not express epithelial or endocrine markers. These histological features indicated those of PEComa. This report underlines that we should recognize PEComa as a preoperative differential diagnosis of pancreatic tumors.

Current status of tissue harmonic imaging in endoscopic ultrasonography (EUS) and EUS-elastography in pancreatobiliary diseases.

Endoscopic ultrasonography (EUS) has high spatial and contrast resolution, and is thought to be one of the most reliable and efficient diagnostic modalities for pancreatobiliary diseases. Recent progress in EUS, especially in the development of the electronic scanning method, has enabled the application of several utilities and software of a high-end transabdominal ultrasound apparatus as an image-enhanced EUS. Tissue harmonic imaging (THI) is a novel US acquisition method that provides better US images by using second harmonic signals. The potential advantages of THI are improved lateral resolution, reduced side lobe artifact and an increased signal-to-noise ratio. EUS-elastography is another novel technique that provides information about the distributed pattern of tissue hardness. Clinical benefits of EUS-elastography for the differential diagnosis of pancreatic tumors and the evaluation of pancreatic fibrosis have been reported. It is necessary to develop a unified and objective method of imaging and analysis to increase the use of EUS-elastography in the future.

F-18 fluorodeoxyglucose positron emission tomography for differential diagnosis of pancreatic tumors.

Positron emission tomography with 2-deoxy-2-[18F]fluoro-D-glucose (FDG-PET) has been proven useful for differentiating pancreatic ductal cancer from mass-forming chronic pancreatitis. However, there are particular pancreatic tumors having various grades of malignancy such as intraductal papillary mucinous neoplasm (IPMN) or pancreatic neuroendocrine tumor. We examined whether the cut-off value of maximum standardized uptake value (SUVmax) determined by pancreatic ductal cancers is also applicable for other pancreatic tumors.One hundred thirty six patients with pancreatic tumors underwent FDG-PET imaging. We first analyzed the cut-off value to differentiate pancreatic ductal cancers from mass-forming chronic pancreatitis. Secondly, we determined the cut-off value between malignant IPMN and benign IPMN. Thirdly, we computed a cut-off value between malignant pancreatic tumors and benign tumors irrespective of tumor type.The optimal cut-off value to differentiate ductal cancers from mass-forming chronic pancreatitis was 2.5. The optimal cut-off value for differentiating malignant IPMN from benign IPMN was also 2.5, similar to that of reported studies. In all types of pancreatic tumors, the cut-off value was also 2.5. The accuracy for detecting malignancy was 93.4% for all tumors.In the FDG-PET study for pancreatic tumors, an SUVmax of 2.5 would be justified as a cut-off value to differentiate malignant lesions.

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.

Mo1480 Contrast Enhanced-Endoscopic Ultrasonography (Ch-EUS) in the Differential Diagnosis of Gastrointestinal Submucosal Tumors (SMTS)

Gastrointestinal SMTs account for a wide variety of etiologies and often pose a significant diagnostic challenge. Endoscopic biopsies show low diagnostic accuracy as these lesions are typically subepithelial. EUS is a useful tool to differentiate true SMTs from extrinsic compressions; however its differential diagnostic capabilities are still suboptimal. Additionally, the accuracy of EUS-fine needle aspiration is reportedly in the range of only 60-70% according to different studies, probably due to the very heterogeneous architecture of SMTs. Recently, CH-EUS has been reported as an useful adjunct in differential diagnosis of pancreatic tumors and lymph nodes. Our aim was to evaluate the potential role of CH-EUS in the differential diagnosis of SMTs.

A Patient With Obstructive Jaundice

Question: A 52-year-old man visited our hospital with a chief complaint of obstructive jaundice. The patient was admitted for detailed examination after a pancreatic tumor was suspected on abdominal ultrasonography. He had a drinking habit, however, he had been previously well. On laboratory examination, his liver chemistry tests were abnormal with total bilirubin at 7.0 mg/dL, alanine aminotransferase at 120 U/L, aspartate aminotransferase at 138 U/L, and alkaline phosphatase at 882 U/L. Serum levels of amylase, carbohydrate antigen 19–9, and carcinoembryonic antigen were normal. He underwent computed tomography (Figure A) and magnetic resonance cholangiopancreatography (Figure B). Endoscopic ultrasonography (EUS) was also performed (Figure C). Because of obstructive jaundice, we performed endoscopic retrograde pancreatocholangiography (Figure D). After endoscopic biliary drainage and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), his laboratory values were normalized, and he was discharged home. What is the diagnosis of this pancreatic lesion? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. On computed tomography, a mass lesion, 30 mm in diameter, in the pancreatic head was detected. Magnetic resonance cholangiopancreatography showed stenosis of the lower bile duct and main pancreatic duct of pancreatic head. EUS showed a tumor having a lateral shadow and a hypoechoic area suggestive of necrosis. Endoscopic retrograde pancreatocholangiography showed stenosis of lower bile duct and main pancreatic duct of pancreatic head. On contrast-enhanced EUS using Sonazoid, no enhancement was observed, and the lesion was thought to be non-neoplastic and diagnosed as pancreatic pseudocyst (Figure E). EUS-FNA was performed with a 19-G needle, and then we performed EUS-guided cystic drainage because of complications by obstructive jaundice.1Pitchumoni C.S. Agarwal N. Pancreatic pseudocysts When and how should drainage be performed?.Gastroenterol Clin North Am. 1999; 28: 615-639Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar Content fluid in this cyst was necrosis (Figure F), and on fluid analysis, pancreatic enzyme was remarkably elevated (amylase, 10,426 U/L; lipase, 71,800 U/L). Cytology of this fluid was negative. He underwent clinical follow-up for 1 year, and the course was compatible with pancreatic pseudocyst. Obstructive jaundice caused solely by pancreatic pseudocyst is rare.2Warshaw A.L. Rattner D.W. Facts and fallacies of common bile duct obstruction by pancreatic pseudocysts.Am J Surg. 1980; 192: 33-37Google Scholar However, its diagnosis is not difficult. If the pancreatic pseudocyst is fully replaced by debris or necrotic tissue, diagnosis is sometimes challenging because it mimics pancreatic tumors. On the other hand, contrast-enhanced endoscopic ultrasonography has been reported to be useful for diagnosis of tumors because it enables the assessment of tumor blood flow.3Gong T.T. Hu D.M. Zhu Q. Contrast-enhanced EUS for differential diagnosis of pancreatic mass lesions: a meta-analysis.Gastrointestinal Endosc. 2012; 76: 301-309Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Contrast-enhanced EUS is promising and should be performed for pancreatic masses because of the clinical usefulness of not only differential diagnosis of pancreatic tumors, but also neoplasm.

Utility of Contrast-Enhanced FDG-PET/CT in the Clinical Management of Pancreatic Cancer

Fluorodeoxyglucose (FDG)-positron emission tomography/contrast-enhanced computed tomography (PET/CE-CT) involving whole-body scanning first by non-CE-CT and FDG-PET followed by CE-CT has been used for detailed examination of pancreatic lesions. We evaluated PET/CE-CT images with regard to differential diagnosis, staging, treatment response, and postoperative recurrence in pancreatic cancer. Positron emission tomography/CE-CT was conducted in 108 patients with pancreatic cancer and in 41 patients with other pancreatic tumor diseases. The maximum standardized uptake value (SUV(max)) overlapped in benign and malignant cases, suggesting that differential diagnosis of pancreatic tumors based on the SUV(max) is difficult. In the evaluation of staging in 31 resectable pancreatic cancer by PET/CE-CT, the diagnostic accuracy rate was more than 80% for most factors concerning local invasion and 94% for distant metastasis but only 42% for lymph node metastasis. Significant positive correlations were found between the SUV(max) and tumor size/markers, suggesting that SUV(max) may be a useful indicator for the treatment response. Regarding the diagnosis of the postoperative recurrence, PET/CE-CT correctly detected local recurrence in all the 11 cases of recurrence, whereas abdominal CE-CT detected only 7 of 11 cases, suggesting that PET/CE-CT is superior in this context. Positron emission tomography/CE-CT is useful for the clinical management of pancreatic cancer.

Castleman disease mimicked pancreatic carcinoma: report of two cases

Castleman disease (CD) is an uncommon benign lymphoproliferative disorder, which usually presents as solitary or multiple masses in the mediastinum. Peripancreatic CD was rarely reported. Herein, we report two cases of unicentric peripancreatic CD from our center. A 43-year-old man and a 58-year-old woman were detected to have a pancreatic mass in the routine medical examinations. Both of them were asymptomatic. The computed tomography and ultrasonographic examination revealed a mild enhancing solitary mass at the pancreatic head/neck. No definite preoperative diagnosis was established and Whipple operations were originally planned. The intraoperative frozen section diagnosis of both patients revealed lymphoproliferation. Then the local excisions of mass were performed. Histological examination revealed features of CD of hyaline-vascular type. No recurrence was found during the follow-up period. CD should be included in the differential diagnosis of pancreatic tumors. Local excision is a suitable surgical choice.

Endosonography in solid and cystic pancreatic tumors.

Pancreatic tumors being either benign or malignant can be solid or cystic. Although diverse in presentation, their imaging features share commonalities and it is often difficult to distinguish these tumors. Endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available for characterizing pancreatic tumors, and is especially good in identifying the smaller sized tumors. Additional applications inclusive of EUS-guided fine needle aspiration (EUS-FNA) are useful in tissue sampling and preoperative staging of pancreatic tumors.Although diagnostic capabilities have greatly evolved with advances in EUS and tissue processing technology (cytology, tumor markers, DNA analysis), differentiation of benign and malignant neoplasms, neoplastic and non-neoplastic (chronic pancreatitis) conditions, continues to be challenging.Recent innovative applications include contrast-enhanced EUS with Doppler mode, contrast-enhanced harmonic EUS, 3-dimensinal EUS, and EUS elastography. Incorporation of these methods has improved the differential diagnosis of pancreatic tumors. Finally, a multi-disciplinary approach involving radiology, gastroenterology and surgical specialties is often necessary for accurate diagnosis and management of solid and cystic pancreatic tumors.

Transabdominal Contrast-Enhanced Ultrasonography of Pancreatic Cancer

Since its introduction, contrast-enhanced ultrasonography (CEUS) has significantly extended the value of ultrasonography (US). CEUS can be used to more accurately determine pancreatic lesions compared to conventional US or to characterize lesions already detectable by US. Thus, CEUS can aid in the differential diagnosis of pancreatic tumors. Using US contrast media, it is possible to visually detect microvessels in the majority of pancreatic ductal adenocarcinomas. Thus, the use of quantitatively evaluated transabdominal CEUS can help in the differentiation of patients with mass-forming pancreatitis from patients with pancreatic adenocarcinomas. In neuroendocrine pancreatic tumors, different enhancement patterns can be observed in relation to the tumor mass: larger ones show a rapid early enhancement sometimes combined with necrotic central structures, and smaller ones disclose a capillary-blush enhancement. Pseudocysts, the most widespread cystic lesions of the pancreas, are not vascularized. They do not show any signal in CEUS and remain entirely anechoic in all phases, while true cystic pancreatic tumors usually have vascularized septa and parietal nodules. In summary, CEUS is effective for differentiating solid pancreatic tumors in most cases. CEUS is safe and cost effective and can better discriminate solid from cystic pancreatic lesions, thereby directing further imaging modalities.

Diagnosis of pancreatic tumors by endoscopic ultrasonography

Pancreatic tumors are highly diverse, as they can be solid or cystic, and benign or malignant. Since their imaging features overlap considerably, it is often difficult to characterize these tumors. In addition, small pancreatic tumors, especially those less than 2 cm in diameter, are difficult to detect and diagnose. For characterizing pancreatic tumors and detecting small pancreatic tumors, endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available. This technique also provides good results in terms of the preoperative staging of pancreatic tumors. EUS-guided fine needle aspiration (EUS-FNA) has also proved to be a safe and useful method for tissue sampling of pancreatic tumors. Despite these advantages, however, it is still difficult to differentiate between benign and malignant, solid or cystic pancreatic tumors, malignant neoplasms, and chronic pancreatitis using EUS, even when EUS-FNA is performed. Recently, contrast-enhanced EUS with Doppler mode (CE-EUS) employing ultrasound contrast agents, which indicate vascularization in pancreatic lesions, has been found to be useful in the differential diagnosis of pancreatic tumors, especially small pancreatic tumors. However, Doppler ultrasonography with contrast-enhancement has several limitations, including blooming artifacts, poor spatial resolution, and low sensitivity to slow flow. Consequently, an echoendoscope was developed recently that has a broad-band transducer and an imaging mode that was designed specifically for contrast-enhanced harmonic EUS (CEH-EUS) with a second-generation ultrasound contrast agent. The CEH-EUS technique is expected to improve the differential diagnosis of pancreatic disease in the future. This review describes the EUS appearances of common solid and cystic pancreatic masses, the diagnostic accuracy of EUS-FNA, and the relative efficacies and advantages of CE-EUS and CEH-EUS along with their relative advantages and their complementary roles in clinical practice.

CK19 and CD10 expression in pancreatic neuroendocrine tumors diagnosed by endoscopic ultrasound‐guided fine‐needle aspiration cytology

CK19 and CD10 are useful markers in the differential diagnosis of pancreatic tumors. The authors evaluated CK19 and CD10 expression in pancreatic neuroendocrine tumors (NETs) obtained by endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Twenty-eight patients diagnosed with pancreatic NETs based on EUS-FNA cytology were studied retrospectively (2004-2007) for immunohistochemical expression of CK19 and CD10. Immunohistochemistry was performed on cell blocks for each case. The pattern of expression for CD10 (cytoplasmic or membranous) and its intensity (0-2) were noted. The staining of the stromal elements for CD10 was recorded as negative. Cytoplasmic staining in tumor cells and percentage distribution (1+ to 4+) for CK19 were regarded as positive. Twenty-three of 28 (82.14%) NETs showed positive cytoplasmic and/or membranous staining for CD10, and 25 of 28 (89.29%) cases were positive for CK19. The findings demonstrate the high expression of CD10 and CK19 in pancreatic NETs. This indicates that CD10 and CK19 cannot reliably differentiate NETs from other tumors with similar cytomorphologic features (solid pseudopapillary tumors, which frequently stain with CD10, and pancreatic adenocarcinoma, which stains with CK19).

Contrast-enhanced endoscopic ultrasound and elastosonoendoscopy

Until recently, there was no contrast harmonic imaging technique available for EUS examination. Second-generation US contrast agents produce harmonic signals at lower acoustic powers and, therefore, are suitable for EUS imaging at low acoustic powers. CE-EUS could provide a contribution to the differential diagnosis between a primary pancreatic carcinoma, chronic pancreatitis and a pancreatic metastasis, and therefore can have a decisive influence on the selection of appropriate therapeutic strategies (follow-up, chemotherapy or surgery, for example). However, histology remains the standard in the differential diagnosis of pancreatic tumours. Regarding lymph nodes, CE-EUS cannot replace EUS-guided fine-needle aspiration. Elastography examines the elastic properties of tissues by applying a slight compression to the tissue and comparing an image obtained before and after this compression. EUS elastography is a new application in the field of endosonography and seems to be able to differentiate fibrous and benign tissue from malignant lesions. While our results are very encouraging, further research will be needed to further define the place of this new technique and should be aimed at further defining criteria for accurate elastography as well as subsequently assessing the technique using multiple operators in a blinded setting. EUS-guided sonoelastography has the potential for further guiding the diagnosis and therapy of gastrointestinal-related tumours.

Study on contrast enhanced EUS in differential diagnosis of pancreatic tumor

Background/Aims: To investigate the feasibility of contrast-enhanced EUS of the pancreas and to describe the characteristics of enhancement of the normal pancreas and the pancreas affected by inflammatory or focal disease.

Differential Diagnosis of Pancreatic Tumors by Molecular Analysis of Clinical Specimens

Objective:To describe the capabilities and limitations of the current state of the art in pancreatic cancer diagnostics and to discuss recent progress in the development of novel, highly accurate molecular diagnostic approaches. Results: Molecular analyses currently under evaluation as novel diagnostic tests include detection of point mutations, genomic imbalances, aberrant methylation patterns and gene expression changes on the mRNA and protein levels in pancreatic juice, fine needle aspiration biopsies and brush cytologies. Conclusions: In exploratory studies, several candidate molecular markers show great potential to serve as general indicators of malignancy, but need to be validated in large, controlled, prospective studies. Multiplexing of diagnostic tests, e.g. in the form of specialized DNA microarrays, may provide more differentiated diagnoses such as the distinction of various tumor types or prognostic information for individual patients. The MolDiag-Paca consortium is strongly engaged in advancing these developments on a European level.

Utility of Contrast-Enhanced Endoscopic Ultrasonography for Diagnosis of Small Pancreatic Carcinomas

The aim of our study was to assess the utility of endoscopic ultrasonography (EUS) and contrast-enhanced EUS (CE-EUS) for the depiction and differential diagnosis of pancreatic tumors focusing in particularly those 2 cm or smaller. We compared different diagnostic procedures, contrast-enhanced multidetector computed tomography (CE-CT) and EUS with the use of power Doppler (PD-EUS) and CE-EUS for detection and differential diagnosis of pancreatic tumors. The study included 156 consecutive patients with suspected pancreatic tumors, who underwent CE-CT, and EUS followed by PD-EUS and CE-EUS. CE-EUS was performed by power Doppler mode using sonographic contrast agent Levovist ®. Thirty-six of 156 patients examined had tumors of ≤2 cm. EUS had significantly higher sensitivity (94.4%) for detection of pancreatic carcinomas of 2 cm or less in comparison to CE-CT (50%). For small pancreatic tumor of 2 cm or less, sensitivities for differentiating ductal carcinomas from other tumors were 50.0%, 11.0% and 83.3% for CE-CT, PD-EUS and CE-EUS. CE-EUS was significantly more sensitive than PD-EUS and CE-CT. EUS and subsequent CE-EUS are more sensitive than CE-CT in the detection and the differentiation of small pancreatic tumors. (E-mail: m-kitano@med.kindai.ac.jp)

Hepatoid Carcinoma of the Pancreas

Hepatoid carcinomas are tumors that display, at least focally, cytologic and/or architectural features of hepatocellular carcinoma. They have been described in several organs, most notably in the stomach and ovary. We report a case of hepatoid carcinoma of the pancreas that developed in a 41-year-old woman in association with a pancreatic endocrine carcinoma. The fine needle aspiration material was characterized by the presence of monotonous, small-to-medium sized tumor cells with round nuclei and finely granular chromatin, intermixed with more atypical tumor cells displaying larger nuclei with coarse clumped chromatin, prominent nucleoli, and moderate amounts of foamy cytoplasm. The excised specimen displayed a poorly differentiated pancreatic endocrine carcinoma associated with well-defined islands of larger tumor cells growing in a perisinusoidal pattern which, based on their immunohistochemical profile and the demonstration of bile, proved to represent a hepatoid component. This case and prior examples in the literature suggest that hepatoid carcinomas of the pancreas appear to be a heterogeneous group of tumors (pure or associated with another histologic component) that are often associated with early liver metastasis and a short survival, although those arising as a component of endocrine tumors seem to fare slightly better. Hepatoid carcinoma of the pancreas should be included in the differential diagnosis of pancreatic tumors composed of large eosinophilic cells.