A Case of Untreated Myeloid Sarcoma of the Pancreas Head Region: Diagnostic Process of AML Subtyping in an Autoptic Case

This study describes an autopsy case of pancreatic/peripancreatic myeloid sarcoma in a 70-year-old man, initially presenting with obstructive jaundice. Pathologically, diffuse infiltration of round cells containing atypical nuclei with marked cleavage was observed mainly in the pancreas head, peripancreatic lymph nodes, spleen, bilateral lung, and bone marrow. Immunohistochemically, the tumor cells were negative for CD20, CD79a, CD3, CD5, c-kit, CD34, and TdT and positive for myeloperoxidase, CD33, CD68, and CD163. Flow cytometry of the peripheral blood showed underexpression of CD11c and aberrant expression of CD56 in the monocyte subset. The peripheral blood smear showed an increase in monocytes and atypia in neutrophils and monocytes, as well as enlarged platelets and polychromatic erythroblasts. Hence, it was suggested that the myeloid sarcoma was derived from the acute transformation of chronic myelomonocytic leukemia. Myeloid sarcoma is an extramedullary-mass-forming hematologic malignancy that is difficult to diagnose, especially when the initial presentation is a pancreatic mass. However, early diagnosis is important for appropriate therapy. Although bone marrow examination could not be performed because of the patients’ severe condition, the pathological specimen obtained with autopsy helped subtype the patient’s leukemia. The immunohistochemical features of this case merit attention.

Pancreas MRI segmentation into head, body, and tail enables regional quantitative analysis of heterogeneous disease

Pancreatic disease can be spatially inhomogeneous. For this reason, quantitative imaging studies of the pancreas have often targeted the 3 main anatomical pancreatic parts, head, body, and tail, traditionally using a balanced region of interest (ROI) strategy. Existing automated analysis methods have implemented whole-organ segmentation, which provides an overall quantification, but fails to address spatial heterogeneity in disease. A method to automatically refine a whole-organ segmentation of the pancreas into head, body, and tail subregions is presented for abdominal magnetic resonance imaging (MRI). The subsegmentation method is based on diffeomorphic registration to a group average template image, where the parts are manually annotated. For a new whole-pancreas segmentation, the aligned template's part labels are automatically propagated to the segmentation of interest. The method is validated retrospectively on the UK Biobank imaging substudy (scanned using a 2-point Dixon protocol at 1.5 tesla), using a nominally healthy cohort of 100 subjects for template creation, and 50 independent subjects for validation. Pancreas head, body, and tail were annotated by multiple experts on the validation cohort, which served as the benchmark for the automated method's performance. Good intra-rater (Dice overlap mean, Head: 0.982, Body: 0.940, Tail: 0.961, N=30) as well as inter-rater (Dice overlap mean, Head: 0.968, Body: 0.905, Tail: 0.943, N=150) agreement was observed. No significant difference (Wilcoxon rank sum test, DSC, Head: p=0.4358, Body: p=0.0992, Tail: p=0.1080) was observed between the manual annotations and the automated method's predictions. Results on regional pancreatic fat assessment are also presented, by intersecting the 3-D parts segmentation with one 2-D multi-echo gradient-echo slice, available from the same scanning session, that was used to compute MRI proton density fat fraction (MRI-PDFF). Initial application of the method on a type 2 diabetes cohort showed the utility of the method for assessing pancreatic disease heterogeneity.

Clinical spectrum of obstructive jaundice: a descriptive crosssectional study

Objective. The objective of this study was to evaluate the clinical spectrum of obstructive jaundice in inflammation, stone disease, and malignancy. Methods. A descriptive observational study was done among 50 patients with the diagnosis of obstructive jaundice during the period 2012 to 2013. A detailed history and clinical examinations and radiological confirmation were done. Results. Among the participants, 74% participants had jaundice, 58% with vomiting as presenting complaints. Among benign cases, 60% were choledocholithiasis, 25% were common bile duct stricture, and 15% were choledochal cyst. Among malignant cases, 26.67% were periampullary carcinoma, 23.33% had carcinoma of the pancreas head, and 13.33% had D2 duodenal carcinoma. Conclusions. The etiology of obstructive jaundice was malignancy in the elderly male population. The most common presenting features were yellowish discoloration of skin and mucosa followed by vomiting and abdominal pain.

A Resected Primary Angiosarcoma of the Pancreas Presenting Aggressive Metastatic Liver Recurrence With Uncontrollable Intraabdominal Bleeding: A Case Report

A 74-year-old man was diagnosed to have a pancreas head tumor (38mm × 32 mm) due to an obstructive jaundice. The patient presented an acute intrabiliary bleeding, while waiting for surgery. Thus, after a coil embolization of the gastroduodenal artery and the anterior/posterior pancreaticoduodenal artery an emergency pancreatoduodenectomy was performed. The patient suffered from grade B delayed gastric emptying, being discharged on postoperative day 33. The pathological diagnosis established was pancreatic angiosarcoma. The patient was re-admitted 4 days after discharge with a general malaise and the loss of appetite. A dynamic computed tomography (CT) and angiography revealed multiple liver metastases and a massive hemoperitoneum. Despite of transcatheter hepatic arterial embolization with gelfoam particles, the patient died 42 days after operation. Six patients with primary angiosarcoma of the pancreas have been reported in English literature so far and this is the first report of unique features of angiogram of multiple liver metastases. The present report allows a deeper knowledge about the aggressive behavior of angiosarcoma of the pancreas.

Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy—Arterial Resection, Arterial Divestment and Total Pancreatectomy

Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.

A case of 18 years disease-free survival after combined pancreatoduodenectomy and hemicolectomy for carcinosarcoma of the transverse colon

Background Ascertaining the origin of large tumors located in the region of the pancreas head and adjacent mesocolon can pose a challenge preoperatively. En bloc pancreatoduodenectomy with hemicolectomy is often required towards curative tumor resection (R0) of malignant tumors in this region. Case presentation Herein we report a case of a 48-year-old man with two contiguous masses each 5 cm in size, located in the pancreatic head. The masses were detected incidentally by abdominal ultrasonography at an annual health check. Endoscopic biopsies revealed inflammation with no malignancy. Cross-sectional imaging showed the tumor direct invasion of the uncinate process of the pancreas, and the third portion of the duodenum. Based on imaging, a malignant submucosal tumor originating from mesenchymal cells in the mesentery of the transverse colon was made preoperatively. The mass required en bloc pancreatoduodenectomy, right hemicolectomy, and resection of the superior mesenteric vein. The final pathology was carcinosarcoma of the transverse colon. The patient survived 18 years after surgery without recurrence. Conclusions Malignant tumors located in the region of the pancreas head should be considered for an en bloc curative tumor resection and adjuvant chemotherapy treatments offered that might be beneficial for carcinosarcoma.