Invasive Large Duct Type Pancreatic Adenocarcinoma: A Diagnostically Challenging Entity

Abstract Introduction/Objective Large duct type invasive pancreatic adenocarcinoma is a morphological variant of pancreatic ductal adenocarcinoma that poses a radiologic and pathologic diagnostic challenge as it closely mimics other non- invasive neoplasms, including mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN). We report a case of large duct type invasive adenocarcinoma that on radiology closely mimics an IPMN. Methods/Case Report The case id that of a 73-year-old male presenting with weight loss and chronic diarrhea. Abdominal imaging revealed features suggestive of main duct IPMN with possible side branch extension into the pancreatic head. Endoscopic retrograde cholangiopancreatography showed a bile duct stricture that was stented and biopsied, revealing mucinous material with neoplastic cells. A Whipple procedure was performed, revealing a 3.3 cm, tank-pink, papillary lesion in the pancreatic head, that is partially cystic with mucinous contents, and displaying exophytic extension into the main pancreatic duct. Microscopically, the lesion consists of a high-grade IPMN involving the main pancreatic duct with side branch extension, and associated with invasive adenocarcinoma, the majority of which is of the large duct type, showing irregularly distributed large ducts with jagged edges and surrounding desmoplasia, with intra-luminal mucinous material and neutrophils. The lining cells show focal pseudo-stratification and bland cytology. Foci of conventional type invasive adenocarcinoma, clusters of invasive tumor cells, and peri-neural invasion are also identified. Post- procedure, the patient underwent chemotherapy with marked symptomatic improvement. Results (if a Case Study enter NA) NA Conclusion Large duct type invasive adenocarcinoma of the pancreas can closely mimic non-invasive pancreatic neoplasms, posing diagnostic challenges that require identification of subtle features to achieve the correct diagnosis and guide treatment.

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A case of intraductal tubulopapillary neoplasm of the pancreas in a branch duct: a rare case report and literature review

BMC Gastroenterology ◽

10.1186/s12876-021-01744-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Atsushi Yamaguchi ◽

Takuro Hamada ◽

Kaoru Wada ◽

Riho Moriuchi ◽

Kanae Tao ◽

...

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Case Reports ◽

Pancreatic Head ◽

Side Branch ◽

World Health ◽

Colonic Surgery ◽

Branch Duct ◽

Intraductal Tubulopapillary Neoplasm ◽

Post Surgery

Abstract Background Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a new disease concept defined by the World Health Organization in 2010. ITPN progresses with tubulopapillary growth in the pancreatic duct and is known to have a fair prognosis. Localization in the main pancreatic duct (MPD) is one characteristic. There are few case reports of ITPN in a branch of the pancreatic duct (BD). Case presentation We encountered a case of ITPN localized in BD. An 85-year-old man was followed after colonic surgery for rectal carcinoma. An abdominal computed tomography scan revealed a cystic mass in the pancreatic head and further examination was done. A T2 weighted intension picture in magnetic resonance imaging showed a 20 mm cystic lesion with an internal mass of 15 mm. Duodenal papilla were slightly open and endoscopic retrograde pancreatography revealed mild and diffuse dilatation of the main pancreatic duct and mucin in the MPD. In consideration with the image examinations, we diagnosed the tumor as an intraductal papillary mucinous neoplasm with carcinoma because of its large mural nodule (> 10 mm in size) in a cyst. Consequently, a pancreaticoduodenectomy was performed. Macroscopically, a white solid tumor sized 2.5 × 1.8 × 1.0 was identified in the head of the pancreas. The cut surface of the resected pancreas showed a side-branch type intraductal tumor with tubulopapillary architecture without mucin secretion. Immunohistochemical staining was positive for MUC1, and negative for MUC2 and MUC5AC. The final diagnosis was determined to be pancreatic ITPN from BD. At the time of this report (48 months post-surgery), the patient remains disease-free without evidence of recurrence. Conclusion ITPNs localized in BD are rare and diagnosis prior to surgery is difficult. In our case, the shape was round, not papillary, and with little fluid. These characteristics are different from a branch duct type IPMN and can be a clue to suspect ITPN in BD.

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Pathomorphological and cytological control of the pancreatic remnant and main pancreatic duct during radical operations in patients with pancreatic adenocarcinoma

Surgery of Ukraine ◽

10.30978/su2019-3-13 ◽

2019 ◽

Vol 0 (3) ◽

pp. 13-18

Author(s):

M. S. Zagriichuk ◽

I. I. Bulik ◽

A. I. Hutsuliak ◽

K. P. Tumasova ◽

Y. V. Nezhentseva ◽

...

Keyword(s):

Pancreatic Duct ◽

Pancreatic Adenocarcinoma ◽

Main Pancreatic Duct ◽

Pancreatic Remnant

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Main pancreatic duct spread in resected invasive ductal adenocarcinoma: A clinicopathological study with propensity score-matched patients

Pancreatology ◽

10.1016/j.pan.2016.06.312 ◽

2016 ◽

Vol 16 (4) ◽

pp. S87

Author(s):

Yasutoshi Kimura ◽

Masayuki Ishii ◽

Shintaro Sugita ◽

Masafumi Imamura ◽

Tatsuya Ito ◽

...

Keyword(s):

Propensity Score ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Ductal Adenocarcinoma ◽

Clinicopathological Study ◽

Invasive Ductal Adenocarcinoma

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Case 4.12

Mayo Clinic Body MRI Case Review ◽

10.1093/med/9780199915705.003.0110 ◽

2014 ◽

pp. 209-209

Author(s):

Christine U. Lee ◽

James F. Glockner

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Side Branch ◽

Cystic Dilatation

71-year-old woman with a possible pseudocyst Anterior (Figure 4.12.1A) and posterior (Figure 4.12.1B) MIP images from 3D FRFSE MRCP reveal marked irregular cystic dilatation of the main pancreatic duct and dilatation of multiple side-branch ducts. IPMN involving the main pancreatic duct...

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Pancreatic neuroendocrine tumor featuring growth into the main pancreatic duct and tumor thrombus within the splenic vein: a case report

Journal of Surgical Case Reports ◽

10.1093/jscr/rjaa155 ◽

2020 ◽

Vol 2020 (7) ◽

Author(s):

Takashi Miyata ◽

Hiroyuki Takamura ◽

Ryosuke Kin ◽

Hisashi Nishiki ◽

Akifumi Hashimoto ◽

...

Keyword(s):

Neuroendocrine Tumor ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Splenic Vein ◽

Pancreatic Neuroendocrine Tumor ◽

Ductal Adenocarcinoma ◽

Pathological Examination ◽

Left Edge ◽

Pancreatic Stump ◽

Pancreatic Body

Abstract A 48-year-old woman was admitted to our hospital because of upper abdominal pain. Computer tomography showed an enhancing mass in the pancreatic body, dilation of the main pancreatic duct (MPD) and a filling defect within the splenic vein. On the basis of the preoperative diagnosis of pancreatic body cancer, distal pancreatectomy was scheduled. The pancreas was divided along the left edge of the gastroduodenal artery; however, frozen pathological examination of the pancreatic stump was tumor positive, and therefore a total pancreatectomy was performed. The lesion was a white expansive nodular mass that had spread into the MPD and protruded into the splenic vein. A pathological diagnosis of non-functioning neuroendocrine tumor (NET) was made. In general, imaging findings of disruption of the MPD and tumor vein thrombus are characteristics of pancreatic ductal adenocarcinoma, but are uncommon in NET. However, NET should be included in the differential diagnosis for such patients.

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Pancreatic head resection preserving the main pancreatic duct for congenital hyperinsulinism of infancy

Pediatric Surgery International ◽

10.1007/s00383-012-3147-x ◽

2012 ◽

Vol 28 (9) ◽

pp. 935-937 ◽

Cited By ~ 4

Author(s):

Masayuki Obatake ◽

Kyoko Mochizuki ◽

Yasuaki Taura ◽

Yukio Inamura ◽

Akiko Nakatomi ◽

...

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Pancreatic Head ◽

Congenital Hyperinsulinism ◽

Pancreatic Head Resection

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Surgical and oncological impact of main pancreatic duct spread in invasive ductal adenocarcinoma: A clinicopathological study of 184 resected cases

Pancreatology ◽

10.1016/j.pan.2015.09.017 ◽

2015 ◽

Vol 15 (6) ◽

pp. 681-687 ◽

Cited By ~ 4

Author(s):

Masayuki Ishii ◽

Yasutoshi Kimura ◽

Shintaro Sugita ◽

Masafumi Imamura ◽

Tatsuya Ito ◽

...

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Ductal Adenocarcinoma ◽

Clinicopathological Study ◽

Invasive Ductal Adenocarcinoma

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Comparison Between Dunking (Invagination) Pancreaticojejunoanastomosis and Double Layer Duct to Mucosa Anastomosis After Cephalic Duodenopancreatectomy-Whipple Procedure for Pancreatic Cephalic Carcinoma

PRILOZI ◽

10.2478/prilozi-2020-0044 ◽

2020 ◽

Vol 41 (3) ◽

pp. 39-47

Author(s):

Aleksandar Shumkovski ◽

Ljubomir Ognjenovic ◽

Stojan Gjoshev

Keyword(s):

Overall Survival ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Double Layer ◽

Main Pancreatic Duct ◽

Pancreatic Head ◽

Postoperative Pancreatic Fistula ◽

Postoperative Reflux ◽

Soft Pancreas ◽

Significant Difference

AbstractIntroduction: Pancreatic cancer is malignancy with poor prognosis for quality of life and overall survival. The incidence is variant, 7.7/100,000 in Europe, 7.6/100,000 in the USA, 2.2/100.000 in Africa. The only real benefit for cure is surgery, duodenopancreatectomy. The key points for this procedure are radicality, low morbidity and low mortality, the follow up and the expected overall survival. The benchmark of the procedure is the pancreaticojejunoanastomosis, with its main pitfall, postoperative pancreatic fistula B or C. Subsequently, the manner of creation of pancreaticojejunoanastomosis defines the safety, thus the postoperative morbidity and mortality. Finally, this issue remarkably depends on the surgeon and the surgical technique creating the anastomosis. We used 2 techniques with interrupted sutures, dunking anastomosis and duct-to-mucosa double layer technique. The objective of the study was to compare these 2 suturing techniques we applied, and the aim was to reveal the risk benefit rationale for dunking either duct to mucosa anastomosis.Material and method: In our last series of 25 patients suffering pancreatic head carcinoma we performed a standard dodenopancreatectomy. After the preoperative diagnosis and staging with US, CICT, tumor markers, they underwent surgery. Invagination-dunking anastomosis was performed in 15, whereas, duct-to-mucosa, double layer anastomosis was performed in 10. In the first group with dunking anastomosis, we had 6 patients with soft pancreas and 8 with narrow main pancreatic duct, less than 3 mm. In the duct-to-mucosa group there were 5 patients with soft pancreas and 4 with narrow main pancreatic duct. All other stages of surgery were unified, so the only difference in the procedure remained on the pancreatojejunoanastomosis. The onset of the postoperative pancreatic fistula was estimated with revelation of 3 fold serum level of alfa amylases from the third postoperative day in the drain liquid.Results: In the duct to mucosa group there wasn’t a clinically relevant postoperative pancreatic fistula, while in the dunking anastomosis group we had 4 postoperative pancreatic fistula B, 26 %. One of these 4 patients experienced intraabdominal collection – abscess, conservatively managed with lavation through the drain. Comparing the groups, there was no significant difference between the groups concerning the appearance of postoperative pancreatic fistula: p>0.05, p=0.125. From all 25 patients, in 21 patients biliary stent was installed preoperatively to resolve the preoperative jaundice. All 21 suffered preoperative and postoperative reflux cholangitis, extending the intra-hospital stay.Conclusion: So far, there have been many trials referring to opposite results while comparing these 2 techniques in creation of the pancreticojejunoanastomosis. In our study, the duct to mucosa anastomosis prevailed as a technique, proving its risk benefit rationale. However, further large randomized clinical studies have to be conducted to clarify which of these procedures would be the prime objective in the choice of the surgeon while creating pancreatojejunoanastomosis.

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Unusual Case of Pancreatic Adenocarcinoma with Bladder Metastasis

Medicina ◽

10.3390/medicina56120708 ◽

2020 ◽

Vol 56 (12) ◽

pp. 708

Author(s):

Giorgia Arcovito ◽

Iosè Di Stefano ◽

Laura Boldrini ◽

Francesca Manassero ◽

Jacopo Durante ◽

...

Keyword(s):

Pancreatic Adenocarcinoma ◽

Locally Advanced ◽

Pancreatic Head ◽

Ductal Adenocarcinoma ◽

Breast Cancers ◽

Disease Case ◽

Diagnostic Hypothesis ◽

Bladder Metastasis ◽

Rare Site ◽

Unusual Occurrence

Background: The pancreas can be the site of neoplasms of several histogenetic origins; in most cases, tumors derive from the exocrine component, and ductal adenocarcinoma certainly prevails over the others. This tumor displays remarkably aggressive behavior, and it is often diagnosed at a late stage of disease. Case presentation: We discuss the rare case of a 76-year-old male with locally advanced pancreatic head adenocarcinoma who developed uncommon metastatic disease. The bladder constitutes a very rare site of metastases, mostly deriving from melanoma, gastric, lung and breast cancers. The bladder’s secondary involvement in pancreatic malignancies represents an extremely unusual occurrence, and there are very few cases described in the literature to date. Conclusions: The finding of pancreatic adenocarcinoma metastases leads to a poor prognosis, and patients who are diagnosed at this stage constitute 53% of cases, with a 5-year survival of 3%. Although rare, therefore, the diagnostic hypothesis of pancreatic ductal adenocarcinoma (DAC) metastases to the bladder must, in some cases, be considered, especially if accompanied by a clinical picture that may suggest it.

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