Ohkura Yu, Sasaki Kazunari, Matsuda Masamichi, Hashimoto Masaji, Fujii Takeshi, Watanabe Goro
Department of Gastroenterological Surgery, Hepato Pancreato Billiary Surgery Unit, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
BMC Med Imaging. 2015 May 7;15:14. doi: 10.1186/s12880-015-0055-2.
Pancreatic cancer accompanied by a moderate-sized pseudocyst with extrapancreatic growth is extremely rare. Diagnosis of pancreatic cancer on preoperative imaging is difficult when the pancreatic parenchyma is compressed by a pseudocyst and becomes unclear. Despite advances in imaging techniques, accurate preoperative diagnosis of cystic lesions of the pancreas remains difficult. In this case, it was challenging to diagnose pancreatic cancer preoperatively as we could not accurately assess the pancreatic parenchyma, which had been compressed by a moderate-sized cystic lesion with extrapancreatic growth.
A 63-year-old woman underwent investigations for epigastric abdominal pain. She had no history of pancreatitis. Although we suspected pancreatic ductal carcinoma with a pancreatic cyst, there was no mass lesion or low-density area suggestive of pancreatic cancer. We did not immediately suspect pancreatic cancer, as development of a moderate-sized cyst with extrapancreatic growth is extremely rare and known tumor markers were not elevated. Therefore, we initially suspected that a massive benign cyst (mucinous cyst neoplasm, serous cyst neoplasm, or intraductal papillary mucinous neoplasm) resulted in stenosis of the main pancreatic duct. We were unable to reach a definitive diagnosis prior to the operation. We had planned a pancreaticoduodenectomy to reach a definitive diagnosis. However, we could not remove the tumor because of significant invasion of the surrounding tissue (portal vein, superior mesenteric vein, etc.). The fluid content of the cyst was serous, and aspiration cytology from the pancreatic cyst was Class III (no malignancy), but the surrounding white connective tissue samples were positive for pancreatic adenocarcinoma on pathological examination during surgery. We repeated imaging (CT, MRI, endoscopic ultrasound, etc.) postoperatively, but there were neither mass lesions nor a low-density area suggestive of pancreatic cancer. In retrospect, we think that the slight pancreatic duct dilation was the only finding suggestive of pancreatic cancer.
It is difficult to diagnose pancreatic cancer with pseudocyst preoperatively. If a pancreatic cyst is found in patients who had normal tumor marker levels or no history of pancreatitis, we should always consider the possibility of pancreatic cancer. In such cases, slight pancreatic duct dilation may be a diagnostic clue.
胰腺癌伴有中等大小且向胰腺外生长的假性囊肿极为罕见。当胰腺实质被假性囊肿压迫而变得不清楚时，术前影像学诊断胰腺癌很困难。尽管影像技术有所进步，但胰腺囊性病变的术前准确诊断仍然困难。在本病例中，术前诊断胰腺癌具有挑战性，因为我们无法准确评估被一个中等大小且向胰腺外生长的囊性病变压迫的胰腺实质。
一名63岁女性因上腹部疼痛接受检查。她没有胰腺炎病史。尽管我们怀疑是伴有胰腺囊肿的胰腺导管癌，但没有提示胰腺癌的肿块病变或低密度区。我们没有立即怀疑胰腺癌，因为中等大小且向胰腺外生长的囊肿极为罕见，且已知的肿瘤标志物未升高。因此，我们最初怀疑一个巨大的良性囊肿（黏液性囊性肿瘤、浆液性囊性肿瘤或导管内乳头状黏液性肿瘤）导致了主胰管狭窄。术前我们未能做出明确诊断。我们原计划行胰十二指肠切除术以明确诊断。然而，由于周围组织（门静脉、肠系膜上静脉等）受明显侵犯，我们无法切除肿瘤。囊肿的液体成分为浆液性，胰腺囊肿穿刺细胞学检查为Ⅲ级（无恶性肿瘤），但手术中病理检查发现周围白色结缔组织样本为胰腺腺癌阳性。术后我们重复进行了影像学检查（CT、MRI、内镜超声等），但既没有肿块病变也没有提示胰腺癌的低密度区。回顾来看，我们认为轻微的胰管扩张是唯一提示胰腺癌的发现。
术前诊断伴有假性囊肿的胰腺癌很困难。如果在肿瘤标志物水平正常或无胰腺炎病史的患者中发现胰腺囊肿，我们应始终考虑胰腺癌的可能性。在这种情况下，轻微的胰管扩张可能是一个诊断线索。
