Letters to the Editor - ISCIIIscielo.isciii.es/pdf/diges/v103n4/carta2.pdf · 2011. 12. 23. · 222...
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Letters to the Editor 1130-0108/2011/103/4/221-222 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright © 2011 ARÁN EDICIONES, S. L. REV ESP ENFERM DIG (Madrid) Vol. 103, N.° 4, pp. 221-222, 2011 Acute recurrent pancreatitis due to an intraductal papillary mucinous tumor of the pancreas Key words: Pancreatitis. Mucinous tumor. Pancreas. Dear Editor, Intraductal papillary mucinous neoplasms of the pancreas (IPMN) are characterized by an adenomatous proliferation of pancreatic duct epithelium involving the main pancreatic duct, the branch ducts alone or a combination of both (1,2). IPMN often presents with acute pancreatitis of mild to moderate severity. It has been reported that approximately one-fourth of patients with IPMN experience symptoms including epigastric discomfort and/or pain and backache (3,4). Case report A 70-year-old man presented with belt-like radiated epigastric pain and elevated pancreatic enzymes: amylase —876 U/l (N < 160 U/l), lipase— 138 U/l (N < 55 U/l). In is past medical history the patient referred similar recurrent pain episodes and there were two recent acute episodes of mild acute pancreatitis. An ab- dominal ultrasonography showed a dilated main pancreatic duct (9 mm), confirmed in an abdominal CT scan (Fig. 1). The ERCP demonstrated mucin extruding from the ampulla (Fig. 2) and se- vere dilation of the main pancreatic duct and secondary branches at the pancreatic head with inner filling defects (Fig. 3). A bal- loon passage (Extractor Rx Retrieval balloon; Microvasive) was performed to remove the mucin from the main pancreatic duct (Fig. 4), brush cytology was performed and a 10 Fr/6 cm plastic stent (Pancreatic Stent, Olympus) was inserted. The cytology in the main pancreatic duct was positive for malignancy (Fig. 5). An MRCP showed a dilated Wirsung s duct without identifying mural nodules. The patient was diagnosed with a malignant IPMN and underwent duodenopancreatectomy. Histology of the surgical specimen confirmed an IPMN with stromal invasion by an adenocarcinoma in the pancreatic isthmus. After seven months of follow-up the patient remains symptom-free and has no evidence of tumour relapse. Discussion IPMN are problematic, both diagnostically and therapeuti- cally, because of the difficulty of preoperative diagnosis, in- cluding the determination of malignant transformation and ex- tension of ductal lesions (5). IPMT are most frequently localized in the main duct of the head region of the pancreas (6). Clinical symptoms of IPMN are different from those of the usual pancreatic cancer as one-fourth of the patients have pan- creatitis-like symptoms (episodes of epigastric pain and hyper- amylasemia) often for many years, especially in patients with mucin-hypersecreting tumors, due to the temporary obstruction of the main pancreatic duct by the viscous mucin (2). Ranges of imaging techniques are used to diagnose IPMN. Abdominal CT often demonstrates pancreatic duct dilation and cystic structures but cannot delineate the type of cyst (2). ERCP is considered the procedure of choice for initial diagnosis with the hallmark combination of intraductal mucin, mucin extru- sion through the papilla and dilation of the main and/or branch pancreatic ducts. MRCP and EUS, which are less-invasive techniques, can identify mural nodules and demonstrate the en- tire ductal system determining the extent of tumour invasion. Rui Ramos, Miguel Areia, Albano Rosa, Rui Gradiz, Paulo Souto, Ernestina Camacho, Hermano Gouveia and Maximino Correia-Leitão Fig. 1. CT scan showing marked dilation of the main pancreatic duct.
Transcript of Letters to the Editor - ISCIIIscielo.isciii.es/pdf/diges/v103n4/carta2.pdf · 2011. 12. 23. · 222...
Letters to the Editor
1130-0108/2011/103/4/221-222REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVASCopyright © 2011 ARÁN EDICIONES, S. L.
REV ESP ENFERM DIG (Madrid)Vol. 103, N.° 4, pp. 221-222, 2011
Acute recurrent pancreatitis due to anintraductal papillary mucinous tumor of the pancreas
Key words: Pancreatitis. Mucinous tumor. Pancreas.
Dear Editor,
Intraductal papillary mucinous neoplasms of the pancreas(IPMN) are characterized by an adenomatous proliferation ofpancreatic duct epithelium involving the main pancreatic duct,the branch ducts alone or a combination of both (1,2). IPMNoften presents with acute pancreatitis of mild to moderateseverity. It has been reported that approximately one-fourth ofpatients with IPMN experience symptoms including epigastricdiscomfort and/or pain and backache (3,4).
Case report
A 70-year-old man presented with belt-like radiated epigastricpain and elevated pancreatic enzymes: amylase —876 U/l (N <160 U/l), lipase— 138 U/l (N < 55 U/l). In is past medical historythe patient referred similar recurrent pain episodes and therewere two recent acute episodes of mild acute pancreatitis. An ab-dominal ultrasonography showed a dilated main pancreatic duct(9 mm), confirmed in an abdominal CT scan (Fig. 1). The ERCPdemonstrated mucin extruding from the ampulla (Fig. 2) and se-vere dilation of the main pancreatic duct and secondary branchesat the pancreatic head with inner filling defects (Fig. 3). A bal-loon passage (Extractor Rx Retrieval balloon; Microvasive) wasperformed to remove the mucin from the main pancreatic duct(Fig. 4), brush cytology was performed and a 10 Fr/6 cm plasticstent (Pancreatic Stent, Olympus) was inserted. The cytology inthe main pancreatic duct was positive for malignancy (Fig. 5).An MRCP showed a dilated Wirsung s duct without identifyingmural nodules. The patient was diagnosed with a malignantIPMN and underwent duodenopancreatectomy. Histology of thesurgical specimen confirmed an IPMN with stromal invasion byan adenocarcinoma in the pancreatic isthmus. After sevenmonths of follow-up the patient remains symptom-free and hasno evidence of tumour relapse.
Discussion
IPMN are problematic, both diagnostically and therapeuti-cally, because of the difficulty of preoperative diagnosis, in-cluding the determination of malignant transformation and ex-tension of ductal lesions (5). IPMT are most frequentlylocalized in the main duct of the head region of the pancreas(6). Clinical symptoms of IPMN are different from those of theusual pancreatic cancer as one-fourth of the patients have pan-creatitis-like symptoms (episodes of epigastric pain and hyper-amylasemia) often for many years, especially in patients withmucin-hypersecreting tumors, due to the temporary obstructionof the main pancreatic duct by the viscous mucin (2).
Ranges of imaging techniques are used to diagnose IPMN.Abdominal CT often demonstrates pancreatic duct dilation andcystic structures but cannot delineate the type of cyst (2). ERCPis considered the procedure of choice for initial diagnosis withthe hallmark combination of intraductal mucin, mucin extru-sion through the papilla and dilation of the main and/or branchpancreatic ducts. MRCP and EUS, which are less-invasivetechniques, can identify mural nodules and demonstrate the en-tire ductal system determining the extent of tumour invasion.
Rui Ramos, Miguel Areia, Albano Rosa, Rui Gradiz, Paulo Souto, Ernestina Camacho, Hermano Gouveia and
Maximino Correia-Leitão
Fig. 1. CT scan showing marked dilation of the main pancreatic duct.
CR_1802-Ramos.ing_PLANTILLA CARTA DIRECTOR 13/04/11 10:36 Página 221
222 LETTERS TO THE EDITOR REV ESP ENFERM DIG (Madrid)
REV ESP ENFERM DIG 2011; 103 (4): 221-222
Department of Gastroenterology. Covilha University Hospital. Coimbra, Portugal
References
1. Itai Y, Ohhashi K, Nagai H, Murakami Y, Kokubo T, Makita K, et al.“Ductectatic” mucinous cystadenoma and cystadenocarcinoma of thepancreas. Radiology 1986;161(3):697-700.
2. Loftus EV Jr., Olivares-Pakzad BA, Batts KP, Adkins MC, StephensDH, Sarr MG, et al. Intraductal papillary-mucinous tumors of the pan-creas: clinicopathologic features, outcome and nomenclature. Mem-bers of the pancreas Clinic, and Pancreatic Surgeons of Mayo Clinic.Gastroenterology 1996;110(6):1909-18.
3. Yamaguchi K, Ogawa Y, Chijiiwa K, Tanaka M. Mucin-hypersecre-ting tumors of the pancreas: assessing the grade of malignancy preo-peratively. Am J Surg 1996;171(4):427-31.
4. Obara T, Maguchi H, Saitoh Y, Ura H, Koike Y, Kitazawa S, et al.Mucin-producing tumor of the pancreas: a unique clinical entity. Am JGastroenterol 1991;86(11):1619-25.
5. Maire F, Couvelard A, Hammel P, Ponsot P, Palazzo L, Aubert A, etal. Intraductal papillary mucinous tumors of the pancreas: the preope-rative value of cytologic and histopathologic diagnosis. GastrointestEndosc 2003;58(5):701-6.
6. Madura JA, Wiebke EA, Howard TJ, Commings OW, Hull MT, Sher-man S, et al. Mucin-hypersecreting intraductal neoplasms of the pan-creas: a precursor to cystic pancreatic malignancies. Surgery 1997;122(4):786-92.
Fig. 2. ERCP demonstrated mucin extruding from the ampulla.
Fig. 4. ERCP balloon removal of the mucin. Fig. 5. Cytological specimen showing carcinoma cells.
Fig. 3. ERCP presenting dilation and filling defect in the main pancrea-tic duct.
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