Resected xanthogranulomatous pancreatitis

A case of progressive xanthogranulomatous pancreatitis with splenic abscess

Xanthogranulomatous inflammation is a chronic inflammatory reaction microscopically characterized by aggregation of foamy histiocytes, fibrous tissue, and infiltration of various inflammatory cells. In contrast to xanthogranulomatous inflammation in the gallbladder or kidney, xanthogranulomatous pancreatitis is rare. We herein present a case of xanthogranulomatous pancreatitis in a patient who underwent distal pancreatectomy with splenectomy under preoperative suspicion of a pancreatic pseudocyst or pancreatic tumor. A 77-year-old woman with a 1 month history of epigastric pain, anorexia, and general fatigue was admitted to our hospital. Contrast-enhanced computed tomography revealed a cystic mass with ill-defined margins at the pancreatic tail together with a splenic abscess. Contrast-enhanced endoscopic ultrasound detected a hyperechoic cystic lesion at the tail of the pancreas with heterogeneous internal echogenicity, and part of the intra-cystic content was enhanced by the contrast agent. Endoscopic retrograde cholangiopancreatography showed a cystic lesion at the tail of the pancreas that continued into the main pancreatic duct, and the main pancreatic duct was slightly narrowed downstream of the cystic lesion. Pancreatic juice cytology revealed suspicious cells, leading to the possibility of intraductal papillary mucinous carcinoma. Distal pancreatectomy with splenectomy was performed, and the histopathological diagnosis was xanthogranulomatous pancreatitis with no malignant findings.

Xanthogranulomatous pancreatitis: A rare entity in the spectrum of pancreatic lesions, a case report

INTRODUCTION

Xanthogranulomatous pancreatitis (XGP) is a rare, benign, and idiopathic disease that often presents with non-specific symptoms and can mimic or coexist with other pancreatic diseases. Despite its infrequency, XGP is frequently misdiagnosed as a pancreatic neoplasm, with only 15 reported cases in the literature. The pathogenesis of XGP remains unclear.

CASE REPORT

We present the case of a 34-year-old woman with no pathological history who experienced continuous abdominal pain and oral intolerance, without signs of cholestasis. An abdominal CT scan initially suggested a cystic neoplasm of the pancreas, leading to a laparotomic cephalic duodenopancreatectomy. The anatomopathological study and immunohistochemistry revealed XGP in association with a mucinous cystic neoplasm with mild to moderate atypia. The patient remained hospitalized for six days post-surgery without any complications.

DISCUSSION

XGP may be induced by the inflammatory reaction secondary to the obstruction of the pancreatic duct by mucin. The etiology is unknown, but it is attributed to a combination of obstruction, hemorrhage, or ductal infection. Abdominal pain is the most common symptom. Differentiating XGP from malignant processes of the pancreatic gland is challenging. Surgical treatment typically involves the Whipple procedure; however, echoendoscopy with biopsy is now available for a more accurate and early differential diagnosis.

CONCLUSION

XGP is a rare and challenging differential diagnosis for pancreatic neoplasms. Due to its potential to mimic malignant lesions, a high index of suspicion is necessary. Echoendoscopy with fine-needle aspiration biopsy should be considered a routine diagnostic tool before major surgery, such as the Whipple procedure.

Pancreatic involvement in Erdheim-Chester disease: a case report and review of the literature

Background

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis characterized by infiltration of lipid-laden foamy macrophages within different tissues. Clinical manifestations of ECD are highly heterogeneous. Bone lesions are found in 80%-95% of patients, while extraosseous lesions usually involve the cardiovascular system, retroperitoneum, central nervous system (CNS), and skin. Pancreatic involvement in ECD has barely been reported.

Case presentation

A 29-year-old female initially presented with menoxenia, diabetes insipidus and diabetes mellitus. 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT) revealed hypermetabolic foci in the bilateral frontal lobe, saddle area, and pancreas. A 99mTc-MDP bone scrintigraphy scan revealed symmetrical increased uptake in distal femoral and proximal tibial metaphysis, which was confirmed to be osteosclerosis by high-resolution peripheral quantitative computed tomography. The patient underwent incomplete resection of the sellar mass. Histological examination of biopsies showed histiocytic aggregates, which were positive for S100 and negative for CD1a and CD207 on immunohistochemistry. Enhanced abdominal CT scan showed hypointense nodules within the body and tail of the pancreas. Endoscopic ultrasonography guided fine-needle aspiration (EUS-FNA) found no evidence of malignancy. She was diagnosed with ECD and treated with high-dose IFN-α. Repeated examinations at three-and eight-months post treatment revealed markedly reduction of both intracranial and pancreatic lesions.

Conclusions

ECD is a rare histiocytic neoplasm that can involve almost every organ, whereas pancreatic involvement has barely been reported to date. Here, we present the rare case of pancreatic lesions in ECD that responded well to interferon-α. We further reviewed reports of pancreatic involvement in histiocytic disorders and concluded the characteristics of such lesions to help diagnosis and treatment, in which these lesions mimicked pancreatic adenocarcinoma and caused unnecessary invasive surgeries.

Juvenile Xanthogranuloma of the Pancreas in a Pediatric Patient Mimicking Pancreatic Neoplasm With High CA 19-9: Case Report and Literature Review

Juvenile xanthogranuloma (JXG) is a rare, non-Langerhans cell histiocytosis. It is usually a benign and self-limiting condition. The most common sites are skin and soft tissue. Pancreatic involvement is extremely rare. We present an unusual case of a 13-month-old female child with JXG of the pancreas and elevated cancer antigen 19-9. JXG should always be considered as a differential diagnosis for pediatric patients presenting with a pancreatic mass, solid and/or cystic in nature. Therefore, avoiding unnecessary invasive diagnostic procedures.

Xanthogranulomatous Pancreatitis Accompanied by Xanthogranulomatous Cholecystitis: A Case Report and Literature Review

ABSTRACT

Xanthogranulomatous pancreatitis (XGP) is extremely rare, with only 31 cases reported in the English literature to date. We reviewed previously reported 17 articles about XGP and report an additional case of XGP. This is the first case of XGP with xanthogranulomatous cholecystitis accompanied by intraductal papillary mucinous carcinoma (IPMC) in an 80-year-old woman. She was referred to our hospital with jaundice and general malaise and was found to have a cystic mass at the pancreatic head and a solid mass at the pancreatic tail, with dilation of both the main pancreatic duct and biliary tract noted on computed tomography. Diagnosis of IPMC at the pancreatic head with neuroendocrine tumor at the pancreatic tail was made, and the patient underwent subtotal stomach-preserving pancreatoduodenectomy with enucleation of the mass at the tail. Pathological examination revealed IPMC with xanthogranulomatous changes around the IPMC and at the pancreatic tail and gallbladder. Xanthogranulomatous pancreatitis could be induced by inflammatory reaction due to obstruction of the pancreatic duct and biliary tract by mucin produced in the IPMC. It is sometimes difficult to preoperatively differentiate XGP from malignant pancreatic tumors, such as pancreatic carcinoma or neuroendocrine tumor, using imaging studies.

Imaging and clinical features of xanthogranulomatous pancreatitis: an analysis of 10 cases at a single institution

PURPOSE

The purpose of the study was to investigate the imaging and clinical features of xanthogranulomatous pancreatitis (XGP).

METHODS

This retrospective series study included 10 patients with pathology-proven XGP. Two radiologists reviewed the computed tomography (CT) and magnetic resonance imaging (MRI) in consensus to determine the morphological features of XGP. The lesion enhancement pattern on dynamic contrast-enhanced scans and the MR signal intensity were also evaluated. Clinical data including symptoms, underlying pancreatic disease, and laboratory findings were reviewed.

RESULTS

Two XGP cases were of a solid type; six were of cystic type, and two were mixed type. XGP usually showed a lobulated contour (90%) and heterogeneous enhancement (100%), with lesion size varying from 2 to 11 cm. Perilesional infiltration was common (90%), but pancreatic duct dilatation was less frequent (30%). Cystic type XGP mostly had an irregular thick wall (83%). On dynamic contrast-enhanced CT/MRI, XGP enhanced progressively from arterial to portal or delayed phases. Lesions appeared hypointense on T1-weighted images (89%) and hyperintense on T2-weighted images (100%). All lesions appeared hyperintense on diffusion-weighted images, with the majority (78%) showing diffusion restriction on apparent diffusion coefficient maps. The patients often had abdominal pain (80%) and underlying pancreatic disease (80%), but mostly had normal or clinically insignificant laboratory findings.

CONCLUSIONS

XGP typically manifests as a clinically silent lobulated heterogeneous mass, with a progressive enhancement pattern and/or irregular thick wall, and diffusion restriction on CT/MRI. Awareness of the imaging and clinical features of XGP may help differentiate it from pancreatic neoplasms, thereby reducing unnecessary surgery.

Xanthogranulomatous pancreatitis mimicking potentially malignant pancreatic neoplasm: report of a case

Xanthogranulomatous pancreatitis (XGP) is a rare benign disease that may mimic or accompany other pancreatic diseases. Here we report a case of XGP initially suspected as malignant cystic neoplasm of the pancreas. A 64-year-old man had been incidentally found to have hypodense lesion at the body of pancreas during a lung cancer workup. All laboratory tests were within normal limits except that carcinoembryonic antigen was elevated to 31.3 ng/ml. Imaging study showed 1.8 cm sized, well demarcated, and low-attenuated mass on computed tomography (CT) with heterogeneously high intensity on T2-weighted images of magnetic resonance imaging (MRI). Under the impression of pancreas cystic neoplasm as a rare case of male solid-pseudopapillary tumor or pancreatic metastasis of lung cancer, laparoscopic distal pancreatectomy was performed. Microscopically, the mass had many foamy histiocytes with cholesterol clefts, consistent with xanthogranulomatous inflammation. Therefore, it is important to consider XGP in the differential diagnosis of pancreatic diseases.

Xanthogranulomatous pancreatitis: A review of the imaging characteristics of this rare and often misdiagnosed lesion of the pancreas

Xanthogranulomatous pancreatitis (XGP) is an extremely rare cause of a cystic pancreatic mass. The pathophysiology of this process is not entirely clear but likely results from a combination of duct obstruction, infection, and repeated hemorrhage. It is difficult to differentiate this inflammatory lesion from a cystic neoplasm and, therefore, in the majority of cases XGP is misdiagnosed as a neoplasm on preoperative imaging. In this report, we describe a case of XGP, the imaging characteristics of XGP, and a differential diagnosis for a cystic pancreatic lesion.

Xanthogranulomatous pancreatitis presents as a solid tumor mass: a case report

Xanthogranulomatous inflammation (XGI) is a rare, idiopathic process in which lipid-laden histiocytes are deposited at various locations in the body. Although XGI has been reported to occur in various organs such as the gallbladder, kidney, bone, stomach, colon, appendix, lymph nodes, urachus, and urinary bladder and in soft tissues, xanthogranulomatous pancreatitis (XGP) is extremely rare. Herein, we report a case of XGP occurring in a 70-yr-old woman, who presented with abdominal pain for several months. On physical examination, mild epigastric tenderness was noted. Abdomen CT scan revealed a low attenuated mass in uncinate process of pancreas, suggesting malignant lesion. Whipple's operation was performed and the final pathologic diagnosis was XGP. The patient's post-operative course was uneventful, and no recurrence was found within 7 months of the operation. When a pancreatic mass does not show clinico-radiological features typical of common pancreatic neoplasms, XGP should be considered for a differential diagnosis.

Xanthogranulomatous pancreatitis combined with intraductal papillary mucinous carcinoma in situ

Xanthogranulomatous lesion is a rare condition in which lipid-laden histiocytes are deposited at various locations in the body. Xanthogranulomatous pancreatitis (XGP) associated with an intraductal papillary mucinous tumor (IPMT) is extremely rare. In this study, we described a case of XGP associated with IPMT and include a review of the literature. A pancreatic cystic mass was detected in a 72-yr-old woman by abdominal computed tomography. Pylorus-preserving pancreaticoduodenectomy was performed and diagnosis of XGP combined with intraductal papillary mucinous carcinoma in situ was made. After 13 months of follow-up, the patient is in good health without any evidence of tumor recurrence. Although XGP associated with IPMT is rare, we suggest that such cases should be brought to the attention of clinical investigators, as it may produce clinical features that mimic pancreatic cancer.

Xanthogranulomatous inflammation of the peripancreatic region mimicking pancreatic cystic neoplasm

Xanthogranulomatous inflammation (XGI) is histopathologically characterized by a marked proliferative fibrosis, parenchymal destruction, and infiltration of foamy histiocytes intermixed with other inflammatory cells. Herein, we report a case of a 73-year-old man without symptoms who was initially diagnosed with a pancreatic cystic tumor but later with XGI in the peripancreatic region. Although XGI has been reported to occur in various organs or tissues, such as the gallbladder, kidney, bone, stomach, colon, appendix, lymph nodes, and soft tissues, XGI involving the pancreas or its surrounding tissues is extremely rare. When a pancreatic cystic lesion does not have typical clinicoradiological features of common pancreatic cystic neoplasms, this pathologic condition should be considered in the differential diagnosis.