Nakahara Seiji, Doi Shunsuke, Nishiwada Satoshi, Yasuda Satoshi, Nagai Minako, Nakamura Kota, Matsuo Yasuko, Terai Taichi, Kohara Yuichiro, Sakata Takeshi, Nitta Yuji, Morita Kohei, Sho Masayuki
Department of Surgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
Department of Diagnostic Pathology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
Surg Case Rep. 2023 Aug 1;9(1):136. doi: 10.1186/s40792-023-01720-w.
Pancreatic lipomas (PLs) arising from the adipose tissue in the pancreatic parenchyma are rare among pancreatic tumors. Coexisting pancreatic ductal adenocarcinoma (PDAC) and PLs have not been previously reported. Herein, we report a case of PDAC arising from the pancreatic parenchyma with chronic pancreatitis compressed by a large PL.
The patient was a 69-year-old male. He had been diagnosed with a PL using computed tomography (CT) 12 years previously. The tumor had been slowly growing and was followed up carefully because of the possibility of well-differentiated liposarcoma. During follow-up, laboratory data revealed liver damage and slightly elevated levels of inflammatory markers. Contrast-enhanced CT revealed the previously diagnosed 12 cm pancreatic head tumor and an irregular isodensity mass at the upper margin of the tumor that invaded and obstructed the distal common bile duct. Magnetic resonance cholangiopancreatography demonstrated no specific findings in the main pancreatic duct. Based on these imaging findings, the patient underwent endoscopic retrograde biliary drainage and bile duct brushing cytology, which revealed indeterminate findings. The differential diagnosis of the tumor at that time was as follows: (1) pancreatic liposarcoma (focal change from well-differentiated to dedifferentiated, not lipoma), (2) distal cholangiocarcinoma, and (3) pancreatic cancer. After the cholangitis improved, a pancreatoduodenectomy was performed. Histologically, hematoxylin-eosin staining revealed moderately differentiated PDAC compressed by proliferating adipose tissue. The adipose lesion showed homogeneous adipose tissue with no evidence of sarcoma, which led to a diagnosis of lipoma. Additionally, extensive fibrosis of the pancreatic parenchyma and atrophy of the acinar cells around the lipoma was suggestive of chronic pancreatitis. The pathological diagnosis was PDAC (pT2N0M0 pStage Ib) with chronic pancreatitis and PL. The postoperative course was uneventful, and the patient was discharged on the 15th day after surgery. The patient received adjuvant chemotherapy and has remained recurrence-free for more than 6 months.
PL may be associated with the development of PDAC in the surrounding inflammatory microenvironment of chronic pancreatitis. In cases of growing lipomas, careful radiologic surveillance may be needed not only for the possibility of liposarcoma but also for the coincidental occurrence of PDAC.
起源于胰腺实质内脂肪组织的胰腺脂肪瘤（PLs）在胰腺肿瘤中较为罕见。此前尚未有胰腺导管腺癌（PDAC）与PLs并存的报道。在此，我们报告一例起源于胰腺实质的PDAC病例，其伴有一个大的PL压迫导致的慢性胰腺炎。
患者为一名69岁男性。12年前经计算机断层扫描（CT）诊断为PL。该肿瘤生长缓慢，因存在分化良好的脂肪肉瘤可能性而进行了仔细随访。随访期间，实验室数据显示肝功能损害以及炎症标志物水平略有升高。增强CT显示先前诊断的12cm胰头肿瘤以及肿瘤上缘一个不规则等密度肿块，该肿块侵犯并阻塞了远端胆总管。磁共振胰胆管造影显示主胰管无特异性表现。基于这些影像学表现，患者接受了内镜逆行胆管引流及胆管刷检细胞学检查，结果显示为不确定结果。当时肿瘤的鉴别诊断如下：（1）胰腺脂肪肉瘤（从分化良好到去分化的局灶性改变，而非脂肪瘤），（2）远端胆管癌，（3）胰腺癌。胆管炎改善后，进行了胰十二指肠切除术。组织学上，苏木精-伊红染色显示中等分化的PDAC被增生的脂肪组织压迫。脂肪病变显示为均匀的脂肪组织，无肉瘤证据，从而诊断为脂肪瘤。此外，胰腺实质广泛纤维化以及脂肪瘤周围腺泡细胞萎缩提示慢性胰腺炎。病理诊断为PDAC（pT2N0M0 p分期Ib）伴慢性胰腺炎和PL。术后病程顺利，患者术后第15天出院。患者接受了辅助化疗，至今已无复发超过6个月。
PL可能在慢性胰腺炎的周围炎症微环境中与PDAC的发生有关。在脂肪瘤生长的病例中，不仅要仔细进行放射学监测以排除脂肪肉瘤的可能性，还要警惕PDAC的同时发生。
