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

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

3. Chief complaint
Jaundice for one week and vomiting several times

4. 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

5. 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

6. Physical examination
Vital sign: T/P/R: / 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 (-)

7. 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

8. Abdominal CT (10/10)

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

11. 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

12. Tumor marker AFP. 1.91 ng/mL 0-20 | CEA. H 3.80 ng/mL 0-3.5
PSA ng/mL | CA H U/mL

13. 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

14. To be continued….

15. 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.

16. Discussion
Mucinous cystadenoma

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

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

19. Synovium Macrocystic adenoma Mucinous cystadenoma
Mucinous macrocystic neoplasm

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

21. 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

22. 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

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

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

25. 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

26. Von Hipple Lindou

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

28. Serous VS mucinous
Radiology 145 : November

29. 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

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

31. Reference Diagnostic imaging- abdomen
Radiology 145 : November
Cystic mass in pancreas Radiographic ;
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