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Vergani C, Messina ME, Giusti I, Venturi M. An incredibly dilated Wirsung mimicking a sero-cystic neoplasm of the pancreatic head. J Surg Case Rep 2018; 2018:rjy122. [PMID: 29977513 PMCID: PMC6007400 DOI: 10.1093/jscr/rjy122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/23/2018] [Accepted: 05/25/2018] [Indexed: 11/13/2022] Open
Abstract
A diabetic patient who at a routine abdominal ultrasounds was found to have a very dilated pancreatic duct. Computed tomography (CT) scan diagnosed a sero-cystic lesion of the pancreatic head. Gastroduodenoscopy discovered a duodenal hyperemic area, which was sampled. Biopsy demonstrated intramucosal vascular emboli from a neuroendocrine carcinoma positive for Chromogranin A and Somatostatin and negative for Gastrin. Cholangio-magnetic resonance imaging revealed that the sero-cystic lesion found at CT, was being mimicked by the enormously dilated pancreatic duct but suggested the possibility of an intraductal or ampullar neoplasm. Blood and urine tests were not helpful and an octreoscan was negative. The patient underwent surgery. Direct exploration confirmed the severe pancreatic duct dilation and a cephalic lesion requiring a pancreatoduodenectomy. Histology confirmed a neuroendocrine tumor infiltrating the duodenum. We conclude that despite modern sophisticated imaging and endoscopic techniques, the evaluation of bilio-pancreatic region can be challenging and can reserve surgical surprises.
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Affiliation(s)
- Contardo Vergani
- Department of Pathophysiology and Transplantation-Unit of Surgery-Università degli Studi di Milano-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Maria Elisa Messina
- Department of Pathophysiology and Transplantation-Unit of Surgery-Università degli Studi di Milano-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Irene Giusti
- Department of Pathophysiology and Transplantation-Unit of Surgery-Università degli Studi di Milano-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marco Venturi
- Department of Pathophysiology and Transplantation-Unit of Surgery-Università degli Studi di Milano-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Cappelli C, Boggi U, Mazzeo S, Cervelli R, Campani D, Funel N, Contillo BP, Bartolozzi C. Contrast enhancement pattern on multidetector CT predicts malignancy in pancreatic endocrine tumours. Eur Radiol 2014; 25:751-9. [PMID: 25447971 DOI: 10.1007/s00330-014-3485-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 09/11/2014] [Accepted: 11/03/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Preoperative suspicion of malignancy in pancreatic neuroendocrine tumours (pNETs) is mostly based on tumour size. We retrospectively reviewed the contrast enhancement pattern (CEP) of a series of pNETs on multiphasic multidetector computed tomography (MDCT), to identify further imaging features predictive of lesion aggressiveness. METHODS Sixty pNETs, diagnosed in 52 patients, were classified based on CEP as: type A showing early contrast enhancement and rapid wash-out; type B presenting even (B1) or only (B2) late enhancement. All tumours were resected allowing pathologic correlations. RESULTS Nineteen pNETs showed type A CEP (5-20 mm), 29 type B1 CEP (5-80 mm) and 12 type B2 (15-100 mm). All tumours were classified as well differentiated tumours, 19 were benign (WDt-b), 15 with uncertain behaviour (WDt-u) and 26 carcinomas (WDC). None of A lesions were malignant (12 WDt-b; 7 WDt-u), all B2 lesions were WDC, 7 B1 lesions were WDt-b, 8 WDt-u and 14 WDC; 4/34 (12 %) lesions ≤2cm were WDC. CEP showed correlation with all histological prognostic indicators. CONCLUSIONS Correlating with the lesion grading and other histological prognostic predictors, CEP may preoperatively suggest the behaviour of pNETs, assisting decisions about treatment. Moreover CEP allows recognition of malignant small tumours, incorrectly classified on the basis of their dimension.
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Affiliation(s)
- Carla Cappelli
- Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy,
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Abstract
Pancreatic neuroendocrine neoplasms (Pan-NENs) are rare but clinically important lesions. Pan-NENs are known for and often categorized by their capacity to produce clinical syndromes mediated by the production of hormones. Despite sometimes presenting dramatically from excessive hormone production, not all Pan-NENs produce functional hormone, and they can pose diagnostic challenges to practicing pathologists. Distinguishing Pan-NENs from mimics can be crucial, because Pan-NENs carry different prognoses and have unique treatments available due to their specific biological properties. This article reviews the current categorization and features of Pan-NENs.
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Affiliation(s)
- J N Rosenbaum
- Department of Surgical Pathology, University of Wisconsin Hospital and Clinics, Room A4/204-3224, 600 Highland Ave., Madison, WI 53792-3224, USA
| | - Ricardo Vincent Lloyd
- Department of Surgical Pathology, University of Wisconsin Hospital and Clinics, Room A4/204-3224, 600 Highland Ave., Madison, WI 53792-3224, USA.
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An L, Li W, Yao KC, Liu R, Lv F, Tang J, Zhang S. Assessment of contrast-enhanced ultrasonography in diagnosis and preoperative localization of insulinoma. Eur J Radiol 2010; 80:675-80. [PMID: 20965676 DOI: 10.1016/j.ejrad.2010.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 09/16/2010] [Accepted: 09/20/2010] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study was to evaluate the value of contrast-enhanced ultrasonography (CEUS) in the diagnosis and preoperative localization of insulinoma and explore the enhancement patterns of the tumors. METHODS Unenhanced and contrast-enhanced ultrasonographic examinations of 31 patients who underwent resection of insulinomas were retrospectively reviewed. The diagnosis sensitivity and localization specificity of CEUS for insulinomas were determined. Results of unenhanced ultrasonography and CEUS were compared by Chi-square test. RESULTS Unenhanced ultrasonography could display 9 of 37 (24.3%) surgically verified insulinomas in 31 patients, while the diagnosis sensitivity and localization specificity of preoperative CEUS was 33 (89.2%) and 32 (86.5%) of the 37 tumors, respectively. In contrast to the unenhanced ultrasonography, the improvement of CEUS in the diagnosis and preoperative localization of insulinomas was significant (p<0.0001). The enhancement pattern of insulinoma on CEUS was fast wash-in and slow wash-out. All the tumors were homogeneous hypervascularity in the earlier arterial phase, while the tumors still displayed hyperenhancing pattern in the late phase. CONCLUSION Our study demonstrates the great potential of CEUS in the diagnosis and preoperative localization of insulinomas. Since CEUS is a convenient, inexpensive, effective and non-invasive modality, the study supports the use of CEUS as a primary tool in the evaluation of patients with insulinomas.
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Affiliation(s)
- Lichun An
- Department of Ultrasound, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, PR China.
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Liu GQ, Qiu FB, Qu YH, Liu N. Epidemiological features, diagnosis and treatment of insulinoma: an analysis of 3 524 cases. Shijie Huaren Xiaohua Zazhi 2010; 18:1620-1623. [DOI: 10.11569/wcjd.v18.i15.1620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the epidemiological features of insulinoma in China during the last 10 years and to analyze its diagnosis and treatment.
METHODS: The reports of insulinoma published from 2000 to 2009 were retrieved from various databases, such as the China National Knowledge Infrastructure (CNKI). The epidemiological features, diagnosis and treatment of the disease were then analyzed.
RESULTS: A total of 3524 patients with insulinoma were reported in China during the last 10 years. The male to female ratio was approximately 1.02:1. The mean age of patients at the time of diagnosis was 40.7 years. Paroxysmal hypoglycemia was the main clinical manifestation of insulinoma. Epileptic manifestations were found in 17.6% of the patients. Surgical resection was the most frequently used procedure for the treatment of insulinoma.
CONCLUSION: Insulinoma is mainly distributed in East and North China. It is difficult to diagnose insulinoma preoperatively. Surgery is effective for the disease. Neoplastic resection is the most frequently used procedure for the treatment of insulinoma.
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Contrast-enhanced sonography of nonfunctioning pancreatic neuroendocrine tumors. AJR Am J Roentgenol 2009; 192:424-30. [PMID: 19155405 DOI: 10.2214/ajr.07.4043] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Diagnosis of malignancy and prognostic assessment continue to be problems in the management of nonfunctioning pancreatic endocrine tumors. Histologic examination is the reference standard. The aim of our study was to compare B-mode and contrast-enhanced sonographic findings regarding nonfunctioning pancreatic endocrine tumors. Signs of malignancy, such as Ki67 index and presence of hepatic metastasis, were considered. MATERIALS AND METHODS We retrospectively reviewed the cases of 38 consecutively registered patients with nonfunctioning pancreatic endocrine tumors evaluated with B-mode and contrast-enhanced sonography and resected. At contrast-enhanced sonography all lesions were divided into hypovascular lesions and isovascular or hypervascular lesions. On the basis of homogeneity of enhancement, lesions were classified as homogeneous and inhomogeneous. During the late phase of contrast enhancement, all solid focal hypoechoic liver lesions detected at contrast-enhanced sonography were considered hepatic metastatic lesions. Among pathologic data, grading, mitotic index, and Ki67 index were evaluated. Spearman's test was used to compare contrast-enhanced sonographic enhancement pattern with pathologic grade. RESULTS In the arterial phase, 24 of 38 nonfunctioning pancreatic endocrine tumors (63.1%) were hypervascular, seven (18.4%) were isovascular, and seven (18.4%) were hypovascular. Positive correlation was found between contrast-enhanced sonographic findings and Ki67 index (r(s) = 0.62; p < 0.0001). The difference between contrast-enhanced and B-mode sonography in the diagnosis of nonfunctioning pancreatic endocrine tumors was statistically significant (p < 0.05). Use of contrast-enhanced sonography increased diagnostic confidence in the detection of hepatic metastasis. The areas under the receiver operating characteristic curves were 0.916 for B-mode sonography and 1.000 for contrast-enhanced sonography (p < 0.05). There was moderate positive correlation between contrast-enhanced sonographic enhancement pattern and the presence of hepatic metastasis at diagnosis (r(s) = 0.46; p = 0.004) and between Ki67 index and the presence of hepatic metastasis (r(s) = 0.48; p = 0.0022). CONCLUSION The contrast-enhanced sonographic enhancement pattern of nonfunctioning pancreatic endocrine tumors has a positive correlation with Ki67 index, which is considered the most reliable independent predictor of the presence of malignancy.
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Norton JA. Tumors of the Endocrine System. Oncology 2007. [DOI: 10.1007/0-387-31056-8_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chang YH, Hsieh MC, Hsin SC, Shin SJ, Lin KD. Insulinoma-associated transient hypothalamus-pituitary-adrenal axis impairment and amelioration by steroid therapy and surgical intervention: a case report. Kaohsiung J Med Sci 2007; 23:526-30. [PMID: 18055299 DOI: 10.1016/s1607-551x(08)70011-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Insulinoma is the most common functional tumor among pancreatic islet cell tumors. This type of tumor is difficult to localize prior to surgery and can lead to serious hypoglycemia. This paper presents the case of a young female who suffered from insulinoma associated with transient hypothalamus-pituitary-adrenal axis impairment. To localize her insulinoma, we used two alternative testing methods, somatostatin receptor scintigraphy and selective arterial calcium stimulation with venous sampling, after a failure of conventional imaging methods. We treated her adrenal insufficiency and prevented serious hypoglycemia by giving her prednisolone. The impairment in her hypothalamus-pituitary-adrenal axis and her serious hypoglycemia recovered after excision of the tumor.
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Affiliation(s)
- Yu-Hung Chang
- Department of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, 100 Shin-Chuan 1st Road, Kaohsiung, Taiwan
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Martínez-Noguera A, D'Onofrio M. Ultrasonography of the pancreas. 1. Conventional imaging. ACTA ACUST UNITED AC 2007; 32:136-49. [PMID: 16897275 DOI: 10.1007/s00261-006-9079-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ultrasound imaging has made significant advances in recent years and plays an important role in the detection, characterization and staging of pancreatic diseases. Conventional ultrasonography (US) is a noninvasive imaging modality, which continues to be the first diagnostic step in the evaluation of the pancreas. Over its various decades of application, US have detected pancreatic pathology of great diversity. This article reviews the wide utility of US and the many examinations techniques, such as filling the stomach with water, changing the patient's position or suspending inspiration or expiration, allowing us to visualize all portions of the pancreas in a high percentage of patients.
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Affiliation(s)
- A Martínez-Noguera
- Department of Radiology, Hospital Sant Pau, Autonomous University of Barcelona, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.
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Falconi M, Plockinger U, Kwekkeboom DJ, Manfredi R, Korner M, Kvols L, Pape UF, Ricke J, Goretzki PE, Wildi S, Steinmuller T, Oberg K, Scoazec JY. Well-differentiated pancreatic nonfunctioning tumors/carcinoma. Neuroendocrinology 2006; 84:196-211. [PMID: 17312380 DOI: 10.1159/000098012] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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McAuley G, Delaney H, Colville J, Lyburn I, Worsley D, Govender P, Torreggiani WC. Multimodality preoperative imaging of pancreatic insulinomas. Clin Radiol 2005; 60:1039-50. [PMID: 16179163 DOI: 10.1016/j.crad.2005.06.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 05/29/2005] [Accepted: 06/01/2005] [Indexed: 12/17/2022]
Abstract
Pancreatic insulinomas are rare tumours of the islet cells of the pancreas, which account for the majority of functional neuroendocrine tumours of the pancreas. There is often a typical history of recurrent hypoglycaemic collapse and dizzy spells. Insulinomas are usually solitary, and the vast majority are intra-pancreatic in location. They are characteristically small with approximately 66% being less than 2cm at presentation. Insulinomas continue to pose a diagnostic challenge to physicians, surgeons and radiologists alike. The role of imaging is to detect and provide precise anatomical localization and staging of tumours prior to surgery. Due to their small size at clinical presentation, they are notoriously difficult to localize radiologically, and specifically designed protocols are necessary to aid detection. In this review, we describe the current "state of the art" imaging protocols that may be used in the preoperative localization of insulinomas.
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Affiliation(s)
- G McAuley
- Department of Radiology, The Adelaide and Meath Hospital incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
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Kianmanesh R, O'toole D, Sauvanet A, Ruszniewski P, Belghiti J. [Surgical treatment of gastric, enteric, and pancreatic endocrine tumors Part 1. Treatment of primary endocrine tumors]. ACTA ACUST UNITED AC 2005; 142:132-49. [PMID: 16142076 DOI: 10.1016/s0021-7697(05)80881-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Endocrine tumors (ET) of the digestive tract (formerly called neuroendocrine tumors) are rare. They are classified into two principal types: gastrointestinal ET's (formerly called carcinoid tumors) which are the most common, and pancreaticoduodenal ET's. Functioning ET's secrete polypeptide hormones which cause characteristic hormonal syndromes. The management of ET is multidisciplinary. Poorly-differentiated ET's have a poor prognosis and are treated by chemotherapy. Surgical excision is the only curative treatment of well-differentiated ET's. The surgical goals are to: 1. prolong survival by resecting the primary tumor and any nodal or hepatic metastases, 2. control the symptoms related to hormonal secretion, 3. prevent or treat local complications. The most common sites of gastrointestinal ET's ( carcinoids) are the appendix and the rectum; these are often small (<1 cm), benign, and discovered fortuitously at the time of appendectomy or colonoscopic removal. Ileal ET's, even if small, are malignant, frequently multiple, and complicated in 30-50% of cases by bowel obstruction, mesenteric invasion, or bleeding. The carcinoid syndrome (consisting of abdominal pain, flushing, diarrhea, hypertension, bronchospasm, and right sided cardiac vegetations) is caused by the hypersecretion of serotonin into the systemic circulation; it occurs in 10% of cases and is usually associated with hepatic metastases. More than half of the cases of pancreatic ET are non-functional. They are usually malignant and of advanced stage at diagnosis presenting as a palpable or obstructing mass or as liver metastases. Insulinoma and gastrinoma (cause of the Zollinger-Ellison syndrome) are the most common functional ET's. 80% are sporadic; in these cases, tumor size, location, and malignant potential determine the type of resection which may vary from a simple enucleation to a formal pancreatectomy. In 10-20% of cases, pancreaticoduodenal ET presents in the setting of multiple endocrine neoplasia (NEM type I), an autosomal-dominant genetic disease with multifocal endocrine involvement of the pituitary, parathyroid, pancreas, and adrenal glands. For insulinoma with NEM-I, enucleation of lesions in the pancreatic head plus a caudal pancreatectomy is the most appropriate procedure. For gastrinoma with NEM-I, the benefit of surgical resection for tumors less than 2-3 cm in size is not clear. The lesions are frequently small, multiple, and widespread and recurrence is frequent after excision. The long-term prognosis is nevertheless fairly good. But the eventual development of liver metastases which are the most common cause of mortality still argues for an aggressive surgical approach in the early stages of the disease.
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Affiliation(s)
- R Kianmanesh
- Fédération d'Hépato-Gastroentérologie, Hôpital Beaujon, Clichy.
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D'Onofrio M, Mansueto G, Falconi M, Procacci C. Neuroendocrine pancreatic tumor: value of contrast enhanced ultrasonography. ACTA ACUST UNITED AC 2004; 29:246-58. [PMID: 15290954 DOI: 10.1007/s00261-003-0097-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- M D'Onofrio
- Department of Radiology, University Hospital G. B. Rossi, Piazza L. A. Scuro, 10, 37134 Verona, Italy.
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