Minute mixed ductal-endocrine carcinoma of the pancreas with predominant intraductal growth

We report a rare case of minute (5 mm x 4 mm) mixed ductal-endocrine carcinoma of the pancreas with predominant intraductal growth. A 34-year-old Japanese man was admitted because of elevated serum pancreatic enzymes. Endoscopic retrograde pancreatography revealed an unidentified material of 18 mm within the main pancreatic duct. Stone or parasite with acute pancreatitis was suspected clinically, and the biopsy revealed malignant cells positive for CA19-9, carcinoembryonic antigen (CEA) and synaptophysin. No apparent tumor was identified in the pancreas by various imaging techniques. Resection of pancreatic body and tail was performed. Grossly, the main pancreatic duct in the pancreatic body was occluded by as much as 20 mm. The pancreas had minute carcinoma of 5 mm x 4 mm just around the occluded main pancreatic duct. The tumor cells invaded the main pancreatic duct and spread within it as long as 20 mm. Histologically, the carcinoma had biphasic pattern; one was ductal carcinoma with tubular formations and another was carcinoma with neuroendocrine features. These two elements were admixed, and the ductal element comprised 30% while the endocrine element comprised 70%. The ductal element was immunoreactive for cytokeratins, CEA and CA19-9, while the endocrine element was immunoreactive for chromogranin A and synaptophysin. No immunoreactivity for pancreatic enzymes was noted. Ultrastructural observations showed dense core granules and no zymogen granules. Our case is unique clinically in that the tumor manifested as an intraductal material and no apparent tumor was found by imaging modalities, and pathologically in that the tumor was rare mixed ductal-endocrine carcinoma and the tumor was very small and mainly grew within the main pancreatic duct.

Nonfunctioning islet cell carcinoma of the pancreas: case report

Islet cell carcinomas have an incidence of 5 per million per year; 50 per cent of these are nonfunctioning islet cell tumors. The presenting symptoms mimic pancreatic ductal adenocarcinoma. The CT finding of a pancreatic head mass that spares the main duct may distinguish between the two. The treatment of choice is resection. Most nonfunctioning islet cell tumors are not discovered until metastases are present. However, favorable survival rates have been reported in locally advanced tumors that have undergone resection. Liver metastases carry an unfavorable prognosis. Five-year survival over 60 per cent has been reported. Node-negative patients have a median survival of more than 10 years, and node-positive patients who have undergone resection have a median survival of 75 months. Streptozotocin and 5-fluorouracil are used postoperatively in patients with advanced disease. Considering the favorable survival with resection aggressive surgical treatment is mandated in cases of nonfunctioning islet cell tumors.

Nonmucinous cystic pancreatic neoplasms

This article discusses serous cystadenomas, the most common of the nonmucinous cystic lesions of the pancreas. These microcystic lesions were previously known as "glycogen-rich" cystadenomas because of the presence of glycogen within the cyst epithelium. A small percentage of these lesions are macrocystic, and it may be difficult to differentiate them from mucinous lesions; however, endoscopic ultrasound guided fine needle aspiration can provide diagnostic material from the cyst fluid. The second most common nonmucinous cyst, the islet cell tumor, is also discussed. These rare cystic tumors may or may not be accompanied by excess hormone production. The prognosis for the rare cystic tumors is good if they are resected successfully.

Streptozocin for treatment of pancreatic islet cell tumors in dogs: 17 cases (1989-1999)

OBJECTIVE

To determine toxic effects of streptozocin given in combination with a diuresis protocol in dogs and establish whether streptozocin is efficacious in treatment of pancreatic islet cell tumors in dogs.

DESIGN

Retrospective study.

ANIMALS

17 dogs.

PROCEDURE

Medical records were reviewed to obtain information regarding signalment, tumor stage and staging tests performed, number of streptozocin treatments, adverse effects, results of biochemical and hematologic monitoring during streptozocin treatment, tumor dimensions, duration of normoglycemia, and date of death, when applicable. Dogs were compared with a historical control group of 15 dogs treated surgically and medically.

RESULTS

58 treatments were administered to the 17 dogs. Only 1 dog developed azotemia. Serum alanine aminotransferase activity increased in some dogs but decreased when treatment was discontinued. Hematologic toxicoses were rare. Vomiting during administration was uncommon but occasionally severe. Two dogs developed diabetes mellitus after receiving 5 doses. Median duration of normoglycemia for 14 dogs with stage-II or -III insulinoma treated with streptozocin was 163 days (95% confidence interval, 16 to 309 days), which was not significantly different from that for the control dogs (90 days; 95% confidence interval, 0 to 426 days). Two dogs had rapid resolution of paraneoplastic peripheral neuropathy, and 2 others had measurable reductions in tumor size.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that streptozocin can be administered safely to dogs at a dosage of 500 mg/m2, IV, every 3 weeks when combined with a protocol for induction of diuresis and may be efficacious in the treatment of dogs with metastatic pancreatic islet cell tumors.

Nonfunctioning islet cell carcinoma of the pancreas associated with massive intra-abdominal hemorrhage

Pancreatic islet cell tumors are rarely associated with intra-abdominal hemorrhage. We report herein a rare case of nonfunctioning islet cell carcinoma associated with massive hemorrhage into the abdominal cavity caused by spontaneous rupture of the tumor. A 44-year-old man presenting with sudden upper abdominal pain was admitted to his local hospital on April 18, 1994. On April 19, a laparotomy was performed with the diagnosis of peritonitis. Massive hemorrhage of unknown origin occurred, and he was transferred to our hospital in a state of hypovolemic shock. Imaging findings revealed massive hematoma in the abdominal cavity and a hypervascular tumor arising from the body of the pancreas. Because the hemorrhage was life-threatening, an emergent re-laparotomy was performed on April 20. Apart from the massive hemorrhage, a pancreatic tumor (60 x 35 x 30 mm in size) with spontaneous rupture was noted. Distal pancreatectomy, combined with splenectomy and removal of the hematoma, was performed. Histological findings revealed an islet cell carcinoma of the pancreas with venous invasion. Peritoneal dissemination, liver metastasis, and lymph node metastasis were not observed. The patient is alive without recurrence 6 years and 5 months after the operation.

The surgical management of pancreatic neuroendocrine tumors

NETs of pancreas are rare and may or may not be associated with symptoms of hormone overproduction. Treatment is required for control of tumor growth and for relief of symptoms associated with excess hormone. With advances in the nonsurgical management of many hormone-related symptoms (e.g., proton pump inhibitors or somatostatin analogues), care for many of these patients has shifted toward the control of tumor progression. Complete surgical resection is the only curative treatment for these tumors. With improvements in the preoperative imaging and intraoperative localization techniques, it is hoped that these tumors will be identified and resected for cure with increased frequency. For patients with hepatic metastasis, initial expectant observation and medical management of symptoms is appropriate in view of the long and indolent course of the disease. Hepatic arterial embolization is the preferred mode of palliation for pain and hormonal symptoms. A curative hepatic resection may be possible in selected patients.

Microcytic adenoma coexistent with low-grade malignant islet cell tumor of the pancreas

We report a case of microcystic (glycogen-rich) adenoma of the whole pancreas with coexistent pancreatic low-grade malignant islet cell tumor in a 29-year-old woman. She complained of nausea, vomiting, and growing abdominal mass. Abdominal computed tomography showed multiple cysts in the whole pancreas and a calcified solid mass in the pancreatic head. A Whipple's operation and total pancreatectomy with splenectomy was performed to treat pancreatic cystic neoplasm. The pancreas was entirely replaced by variable-sized, multilocular cysts, which were lined by a flattened-to-cuboidal glycogen-rich epithelium. Furthermore, in the head of the pancreas, a focal yellowish solid mass showed a positive reaction for chromogranin A and neuron-specific enolase. Careful examination of the pancreas is warranted in cases of microcystic adenoma to rule out a possible coexistent pancreatic malignancy.

Malignant islet cell tumor projecting into the main pancreatic duct

We report herein a rare case of islet cell tumor showing a unique growth pattern in a patient who developed repeated acute pancreatitis as the tumor's initial symptom. Preoperative imaging examinations showed dilatation of the main pancreatic duct (MPD) and cysts around the pancreatic tail. A distal pancreatectomy with splenectomy was performed because the pancreatitis was localized in the distal pancreas and was not controlled by various drug therapies. Grossly, the tumor consisted of two component parts: a markedly infiltrative part in the pancreatic parenchyma, and a papillary elevated part in the MPD. The MPD was obstructed by the tumor spreading widely along the distal MPD. Microscopically, the tumor was composed entirely of islet cell tumors (nonfunctioning), with several foci of venous and lymphatic involvement. Based on its growth behavior, we assumed that the tumor may have arisen from the MPD or from islet cells closely adjacent to the MPD. The patient's postoperative course was uneventful and he is doing well 2 years after the operation. We discuss the growth pattern of the tumor and the cause of the pancreatitis.

Islet cell tumours: surgical treatment

The majority of neuroendocrine tumours of the pancreas are malignant and surgical resection is the mainstay of treatment. The tumours are often small and intraoperative tumour localization is an important part of the operation. The type of tumour will dictate specific treatment.

Management of nonfunctioning islet cell carcinomas

Tumors arising from the pancreatic islet cells are rare and represent a heterogeneous group of benign or malignant lesions. Most tumors present with well characterized syndromes, whereas others appear to be nonfunctioning. The clinical features of 11 men and 7 women with nonfunctioning islet cell carcinomas operated on between 1983 and 1998 were reviewed. The median patient age was 53.5 years (range 26-74 years). The most frequent presenting symptoms were abdominal pain (13 patients), weight loss (7 patients), and obstructive jaundice (4 patients). Gut hormone profiles were normal in all patients. Abdominal sonography and computed tomography localized the tumor in 17 patients, and correct prediction of an endocrine tumor was achieved in 12 patients. Six of seven patients showed a hypervascular tumor upon angiography, and seven of eight patients preoperatively had positive somatostatin receptor scintigraphy. At operation, regional or distant metastases were present in 15 (83%) and 6 (33%) patients, respectively. Eleven patients underwent potentially curative resections, and the remaining seven patients were managed palliatively by resection (four patients) or bypass procedures (three patients). Three patients had up to three more resection for metastases. Eight patients received postoperative octreotide, interferon alpha therapy, or both. The overall cumulative 5- and 10-year survival rates were 65.4% and 49.1%, respectively. Of the 11 patients who underwent curative resection, 10 were alive after a median follow-up of 63 months (range 7-180 months), but only 5 are free from disease. Although surgical cure is rare in nonfunctioning islet cell carcinomas, significant long-term palliation can be achieved in a large proportion of patients with an aggressive surgical approach and, when indicated, additional medical therapy.

Resection of a non-functioning islet cell carcinoma occupying the entire pancreas

A 46-year-old woman with jaundice was found to have enlargement of the entire pancreas on computed tomography. Endoscopy revealed a tumor at the papilla of Vater, although examination of biopsy specimens did not demonstrate a malignancy. The jaundice resolved spontaneously, but reappeared at 7 months. Also noted was increased swelling of the papilla. The serum pancreatic endocrine and exocrine hormone concentrations were within the reference ranges. At surgery, a hard mass was found occupying the entire pancreas. Examination of incisional biopsy specimens from the pancreatic mass and papilla of Vater revealed an islet cell tumor. A total pancreatectomy was performed. The tumor extended from the pancreatic tail to the papilla of Vater. Histopathologic and immunopathologic examination revealed a non-functional islet cell carcinoma. There was no evidence of recurrence at 3 years. A good outcome can be achieved with resection of non-functioning islet cell carcinomas, even if they are advanced.

Nonfunctioning islet cell carcinoma of the pancreas with high serum CEA & CA19-9, K-ras codon 12 mutation, and microsatellite instability

A 55-year-old man with nonfunctioning islet cell carcinoma showing elevation of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels is described with genetic analyses. Pathological examination of the resected specimen revealed two independent islet cell carcinomas, one in the body and the other in the tail of the pancreas. It was proved immunohistochemically that the tumor cells, particularly those in the tail, were immunoreactive to CEA and CA 19-9 and had the property of duct cells, as well as endocrine cells. Gastrin was demonstrated immunohistochemically in these tumor cells, although its level in serum was not elevated. Genetic analyses of the fresh specimens from the tumor in the body revealed K-ras codon 12 mutation and microsatellite instability. These findings are consistent with its progressive clinical course and strongly suggest that these tumors originate, not from the islet cells of Langerhans, but from protodifferentiated cells, capable of giving rise to all the pancreatic cell types.

Protocol for the examination of specimens from patients with endocrine tumors of the pancreas, including those with mixed endocrine and acinar cell differentiation: a basis for checklists. Cancer Committee of the College of American Pathologists

No Abstract Available

Nonfunctioning pancreatic tumor manifestated as abdominal mass in a child

This report concerns a 9-year-old girl with a nonfunctioning pancreatic tumor presented as an abdominal mass. An encapsulated tumor, measuring approximately 8 x 7 cm, was found during operation, and debulking surgery was done. Histopathologic studies proved that it was a pancreatic tumor, compatible with non-functioning islet cell tumors. She displayed neither clinical picture of jaundice, nor excessive hormonal manifestations such as diarrhea or flushing. No evidence would suggest its association with multiple endocrine neoplasia type I. To our knowledge, it has never been reported in children in Taiwan.

Nonfunctioning islet cell carcinoma of the pancreas: an evaluation of seven patients who underwent resection followed by long-term survival

Islet cell carcinoma of the pancreas is a rare, indolent malignancy associated with a higher resectability rate and better survival than ductal carcinoma. This retrospective study presents the results of surgical treatment for nonfunctioning islet cell carcinoma of the pancreas in seven patients diagnosed and treated at Kurume University Hospital. There were two men and five women, with an average age of 54 years. Of the five tumors, four were located in the head of the pancreas, and the other three tumors were located in the body or tail of the pancreas. Epigastric pain was frequently the primary clinical symptom. By the time of diagnosis, four of the patients had regional disease, one of whom had lymph node and liver metastases, and one, liver metastases. Another patients was found to have lymph node metastases intraoperatively. Only one of the patients died of recurrent cancer, 21 years after the original operation. All of the patients who had liver metastases at the time of initial surgical treatment are now living at home. Thus, we conclude that nonfunctioning islet cell carcinomas are slow-growing tumors with a good prognosis if the main tumors and metastatic lesions are removed.

Rare pancreatic tumours in children (other than nesidioblastosis)

BACKGROUND

The rarity of pancreatic tumours other than nesidioblastosis in children is such that the experience of any one surgeon or institution is small. As a consequence, there is limited information on the appropriate management and outcome of these tumours. For this reason a review was conducted of the experience of a large paediatric surgical institution.

METHODS

During a 23-year period, six patients with pancreatic tumours other than nesidioblastosis were treated at the Royal Children's Hospital, Melbourne.

RESULTS

Despite the varied modes of presentation and surgery undertaken, all six patients with surgery alone, with follow-up from 1 to 18 years. Two of the tumours were malignant; the remaining four being islet cell adenomata. No form of adjuvant treatment (chemotherapy or radiotherapy) was used.

CONCLUSION

These rare paediatric tumours appear to have a good prognosis, even when malignant, and respond well to radical surgical ablation. Adjuvant therapy appears to be unnecessary.

Resolution of superficial necrolytic dermatitis following excision of a glucagon-secreting pancreatic neoplasm in a dog

An 11-year-old, neutered male standard poodle was diagnosed with superficial necrolytic dermatitis and a glucagon-secreting pancreatic islet neoplasm based on clinical, biochemical, histopathological, immunohistochemical, and hormonal findings. Hyperglucagonemia, hyperinsulinemia, and hypoaminoacidemia were observed on preoperative laboratory analysis. Abnormal laboratory values returned to normal, and complete resolution of skin lesions occurred after tumor excision. The dog has remained clinically normal for six months following surgery.

Islet cell carcinoma of the pancreas

Islet cell carcinoma (ICC) of the pancreas is a rare, indolent malignancy associated with higher resectability rate and better survival than ductal carcinoma. This retrospective study presents results of surgical treatment from a single institution. From 1985 through 1993 a total of 64 patients (36 men, 28 women) were surgically treated for ICC. Ages ranged from 22 to 80 years (median 55 years) with a median postoperative follow-up of 39 months (range 10-97 months). Of the 64 patients, 30 (47%) had functioning and 34 (53%) nonfunctioning tumors. Gastrinoma (n = 11) followed by glucagonoma (n = 6) and insulinoma (n = 4) were the most common functioning tumors. In the patients undergoing a laboratory study, 67% of the nonfunctioning tumors had elevated peptide hormone levels. Potentially curative resections were performed in 17 patients (26%), palliative procedures in 35 (55%), and exploratory laparotomy alone in 12 (19%). One patient (2%) died within 30 days after operation. Symptomatic improvement was achieved in 96% of patients with a mean duration of 22 months. Three- and five-year survivals were 66% and 49%, respectively. In patients with curative resection, the disease-free survival at 3 years was 53% (95% CI: 32-86%). The presence of diffuse hepatic metastases was a predictor of poor survival at 3 years (74% versus 58%;p = 0.05); there was no statistically significant difference in survival between functioning and nonfunctioning groups (p > 0.1). Although curative resection for ICC is rare, meaningful palliation can be achieved in most patients with rare mortality and acceptable morbidity.

Early massive accumulation of In-111 pentetreotide in a metastatic liver tumor of islet cell carcinoma

A 62-year-old woman was examined with In-111 pentetreotide and Ga-67 citrate. She had undergone an operation to resect a neuroendocrine tumor of the pancreas and still had masses in the liver. One of her hepatic lesions had been biopsied and acinar cell carcinoma was suspected. Fluid in the cyst of the tumor, however, contained a high concentration of gastrin and the tumor was strongly suspected of being a metastasis from the neuroendocrine tumor of the pancreas. The hepatic tumors quickly accumulated In-111 pentetreotide immediately after the injection, but there was no Ga-67 citrate uptake in the tumor. Five months after pentetreotide scintigraphy, her hepatic tumors were resected and histologically proven to be metastasis of islet cell carcinoma. In-111 pentetreotide provides information of the somatostatin-receptor status on the tumor and supports the diagnosis made by hormonal survey.

Cystic tumors of the pancreas

Cystic neoplasms of the pancreas are relatively uncommon lesions that should not be confused with pancreatic pseudocysts. Guidelines for this differential diagnosis, the characteristics of the more common varieties, and the authors' experience with 130 cystic tumors are described.

Islet cell tumors of the pancreas

Pancreatic endocrine neoplasms are a heterogeneous group of tumors that produce active hormones and result in distinct clinical syndromes. For the most part, they are malignant and require sophisticated diagnostic and localization techniques in order to identify their presence. Delays in diagnosis are the rule rather than the exception. Improvements in the diagnosis of gastrinomas and insulinomas appear to result in an increase in resectability rates. The widespread availability of intraoperative ultrasonography, as well as improved knowledge of the location of these tumors, has also had an impact on improved cure rates. With heightened awareness of these syndromes, increasing numbers of patients can be identified and more effective treatments developed for the refractory and recurrent tumors.