Ito Hiroyuki, Kawaguchi Yoshiaki, Kawashima Yohei, Maruno Atsuko, Ogawa Masami, Hirabayashi Kenichi, Mine Tetsuya
Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan.
Department of Pathology, Tokai University School of Medicine, Isehara, Japan.
Case Rep Oncol. 2015 Jan 22;8(1):30-6. doi: 10.1159/000371842. eCollection 2015 Jan-Apr.
A 63-year-old female patient presented to a local physician with pain in her back and epigastric region. An abdominal computed tomography (CT) scan revealed a pancreatic tumor, and the patient was referred to our hospital. Multiple imaging studies that included ultrasonography (US), CT, MRI, and endoscopic US revealed a cystic lesion 3-4 cm in size with node-like projections in the body of the pancreas. The distal main pancreatic duct was also found to be dilated. Endoscopic retrograde pancreatography revealed an irregular stenosis of the main pancreatic duct proximal to the cystic lesion, and malignancy was suspected. The patient was preoperatively diagnosed with pancreatic ductal carcinoma concomitant with intraductal papillary mucinous carcinoma, and a distal pancreatectomy was performed. Rapid pathological diagnosis during surgery revealed positive surgical margins for pancreatic intraepithelial neoplasia (PanIN). Further resection was performed twice, her surgical margin was positive and total pancreatectomy was ultimately conducted. Histopathological findings revealed diffuse microinvasive cancerous lesions corresponding to PanIN-2 (moderate dysplasia) to PanIN-3 (carcinoma in situ) throughout the pancreas. PanIN involves microlesions of the ductal epithelium that may precede pancreatic cancer. Ascertaining changes in PanIN using images provided by diagnostic modalities such as CT and US is challenging. Ductal stenosis and distal cystic lesions resulting from atrophy and fibrosis of pancreatic tissue were noted around PanIN. Considering the possibility of PanIN, a precancerous lesion during differential diagnosis will help to improve early detection and prognosis for patients with pancreatic cancer.
一名63岁女性患者因背部和上腹部疼痛就诊于当地医生。腹部计算机断层扫描（CT）显示胰腺肿瘤，该患者被转诊至我院。包括超声检查（US）、CT、磁共振成像（MRI）和内镜超声检查在内的多项影像学研究显示，胰腺体部有一个3 - 4厘米大小的囊性病变，并伴有结节样突起。还发现胰腺远端主胰管扩张。内镜逆行胰胆管造影显示囊性病变近端的主胰管有不规则狭窄，怀疑为恶性。该患者术前诊断为胰腺导管癌合并导管内乳头状黏液癌，并进行了远端胰腺切除术。手术中的快速病理诊断显示胰腺上皮内瘤变（PanIN）的手术切缘阳性。又进行了两次进一步切除，其手术切缘仍为阳性，最终进行了全胰腺切除术。组织病理学检查结果显示，整个胰腺存在弥漫性微浸润癌性病变，对应于PanIN - 2（中度发育异常）至PanIN - 3（原位癌）。PanIN涉及导管上皮的微病变，可能先于胰腺癌出现。利用CT和US等诊断方式提供的图像来确定PanIN的变化具有挑战性。在PanIN周围注意到胰腺组织萎缩和纤维化导致的导管狭窄和远端囊性病变。在鉴别诊断时考虑PanIN这种癌前病变的可能性，将有助于提高胰腺癌患者的早期检测率和改善预后。
