Intern seminar -case presentation Date: 2006/10/25 Speaker: Int. 李明吉 林君賢

Identifying Information Name: 陳XX Age：45 y/o Gender:male Bed No.：6C87A 8A15A Admission date：2006/10/10

Chief complaint Jaundice for one week and vomiting several times

10/9 10/10 1.persist epigastric dull pain, radiated to back 2.vomiting several times on 10/09 night. Dr. 林信常. :Abd. echo 5.7 * 6.4 cm sized cystic lesion in pancreatic head with CBD and IHD dilatation.refer to ER body weight loss (10-15Kg) for 2-3 months general weakness, poor appetite. 10/9 10/10 ER: Sclera: icteric Epigastric pain GOT/GPT ↑ , Bil-T/D↑ Fever(-) in recently days HBV, HCV history(-) Abd CT with contrast admission jaundice, tea colored urine, and clay stool for one week

Past history 1. Hypertension 2. Frontal sinus, Lefort I & II fracture and mandible fracture s/p ORIF 10 years ago 3. smoking (+), 1/2 PPD for several years 4. drinking (+): social

Physical examination Vital sign: T/P/R: 36.5 / 74 / 18 BP: 159 / 108 mmHg Consciousness: clear (E4V5M6) Pupil: (3/3, +/+) HEENT: Conjunctiva: pink; Sclera: icteric Neck: supple; JVE (-); LAP (-) Chest: Symmetric expansion BS: bilateral clear HS: RHB Abdomen: Bowel sound: normactive, soft Tenderness (+), rebound pain (-), muscle guarding (-) Extremity: pitting edema (-)

Lab Data Hemo-gram WBC RBC Hb Hct MCV MCH Platelet PT 11.4K 4.76M 15.4 44.7 93.9 32.4 414K 10.7 Band Seg. Eos. Baso. Mono. Lymph. Aty-lym aPTT - 78.3 0.5 0.4 6.6 14.2 27.4 Bioche-misry Glu-PC BUN Crea GOT GPT CRP Bil-T Bil-D 117 13 0.8 114 166 68.2 11.8 10.3 Na K lipase Amyl ALK-P LD Alb Ca/P 139 3.5 282 152 909 213 3.8 9.7/4.4 U/A SG pH Bil UBG 1.020 7.0 1-2 3 4.0

Abdominal CT (10/10)

cystic mass,about 7cm, in the pancreatic head with septum, calcification and dilated biliary and pancreatic duct. favor mucinous cystadenoma or cystadenocarcinoma.

10/10 10/11 10/16 Admission IVF support 上腹痛Pain control : demerol prn or tramadol ENBD:墨綠色 700~1000ml/day Bile fluid cytology :negative for malignancy 10/10 10/11 10/16 Transfer to GS Prepare for OP on 10/25 s/p ENBD on 10/11 Consult GS

Tumor marker AFP. 1.91 ng/mL 0-20 | CEA. H 3.80 ng/mL 0-3.5 PSA. 0.922 ng/mL 0-4 | CA 199 H 39.34 U/mL 0-34

Lab data progress 10/13 10/15 10/19 10/23 Bil-T/D 4.4/3.2 3.7/2.8 3.1/2.2 2.4/1.7 GOT/GPT 49/75 57/77 38/49 39/61 Amy/Lip - 161/797 191/not check 318/1678 ALK-P 538 324 360 GGT 481(10/14) 225 239 W/Hb/P 10.7/13.6/364 9.8/12.1/379 10.3/14.3/502

To be continued….

Echo in LMD Coarse echogenicity of the liver, main bile duct was measured about 0.92cm Both IHD were dilated. a cyst lesion 5.7 * 4.6 cm in pancreatic head.

Discussion Mucinous cystadenoma

D/D of cyst in pancreas If tumor, image alone to D/D is not enough

morphology Cystic Pancreatic Lesions: A Simple Imaging-based Classification System for Guiding Management1 RadioGraphics 2005; 25:1471–1484

Synovium Macrocystic adenoma Mucinous cystadenoma Mucinous macrocystic neoplasm

Epidemology Primary tumor of pancreas Potential malignant Frequency: 10% pancreatic cyst and 1 % pancreatic neoplasm

Clinical presentation Age: mean 50y/o, range from 20-95y/o, F:M=6:1 Most common s/s: Asymptomatic, epigastralgia, palpable mass Mass effect on adjacent organ: ex. Jaudice Rare meta or local invasion Lab: CEA increased CA199 increase in cystic fluid

CT findings Hypodense unilocular/multilocular cyst Thicked-wall Amount < 6 Size:>2cm Thicked-wall Most common in pancreatic tail Enhanced multiseptated mass Focal calcification: 16% Size: 2-12 cm Serous 多central scar calcification

Typical finding Cystic Pancreatic Lesions: A Simple Imaging-based Classification System for Guiding Management1 RadioGraphics 2005; 25:1471–1484

Intramural cyst Imaging Diagnosis of Cystic Pancreatic Lesions: Pseudocyst versus Nonpseudocyst1 RadioGraphics 2005; 25:671–685

Differential diagnosis Pseudocyst Serous cystadenoma True cyst( Congenital cyst): ex: vHL(multiple), ADPKD Intraductal papillary mucinous tumor(IPMT) vHL除了pancreas 有cyst，liver, spleen, adrenal gland, kidney亦可見 IPMT多男性，從p-duct長出

Von Hipple Lindou

IPMT Imaging Diagnosis of Cystic Pancreatic Lesions: Pseudocyst versus Nonpseudocyst1 RadioGraphics 2005; 25:671–685

Serous VS mucinous Radiology 145 : 419-425 1982 November

Pathology finding Larged encapsulated mass,smooth and round Multi/unilocular large cyst:2-12 cm Thin septum:<2mm Cyst content: thick mucoid material, clear, green, blood tinged fluid Solid papillary projection into cavity: cancer sign

Management Cystic Pancreatic Lesions: A Simple Imaging-based Classification System for Guiding Management1 RadioGraphics 2005; 25:1471–1484

Reference Diagnostic imaging- abdomen Radiology 145 : 419-425 1982 November Cystic mass in pancreas Radiographic 1992 12;673-686 Imaging Diagnosis of Cystic Pancreatic Lesions: Pseudocyst versus Nonpseudocyst1 RadioGraphics 2005; 25:671–685 Cystic Pancreatic Lesions: A Simple Imaging-based Classification System for Guiding Management1 RadioGraphics 2005; 25:1471–1484