Case Capsule

1. PANCREATIC MASS
Moderator: Dr K.R.Palaniswamy
Senior consultant,
Dept of Gastroenterology,
Apollo Hospitals, Chennai
TNISGCON 2015
PANEL DISCUSSION

2. Panelists
• Dr Anil Arora
• Dr G.N.Ramesh
• Dr R.Surendran
• Dr Rochita
• Dr Ashok Parameswaran

3. History
• 47 y, male
• Diabetic : 7 yrs
-recent worsening in last 3 months
• Left upper abdominal pain: 6 months
-intermittent , each episode lasting for 15 min
• Back pain: 15 days; continuous, moderate
• Weight loss -3 kgs in 3 month
• No h/o anorexia, vomiting

4. Examination
• Moderately built
• No pallor/ icterus or lymphadenopathy
• Abdomen: Soft, non tender. No palpable mass

5. Questions
• Dr Anil Arora: What are the possibilites?
• Dr Ramesh: How will you proceed?

6. Previous investigations
• CBC-N
• LFT,RFT-N
• Amylase, Lipase: Normal; CA 19-9: Normal
• USG abdomen:
– Ill defined echopoor mass of 27mm in body of
pancreas.
– Gallbladder wall thickened with a 5mm polypoid
mucosa

7. CECT ABDOMEN

8. Questions
• Dr Rochita: Comment on CT abomen

9. CECT abdomen
• Ill defined hypodense mass lesion 3.9 x 2.3 cms seen
in uncinate process with minimal fat stranding
• Another mass in body of pancreas 2.3 x 2.5 cms seen
in body of pancreas abutting splenic artery
• Both lesions show contrast enhancement
• MPD mildly prominent in body with parenchymal
atrophy in body and distal tail
• Small peripancreatic nodes
• Imp: Possiblity of pancreatic malignancy to be
considered

10. Questions
Dr Anil Arora: How to proceed?

11. Dr Ramesh: Role of EUS in
pancreatic malignancy?

12. Gress et al. GI Endoscopy 1999

13. EUS diagnostic accuracy
• Staging sensitivity with EUS has consistently
been reported to be over 90%.
• EUS is also more accurate in the assessment
of vascular invasion that might preclude
surgical resection (compared to h-CT/MRI)
Rösch et al. Gastrointest Endosc Clin N Am 1995;5:735-9.
Yasuda et al. Endoscopy 1993;25: 151-5.
Palazzo et al. Endoscopy 1993;25:143-50.
Brugge et al. GI Endosc 1996;43:561-7.

14. Pancreatic CancerPancreatic Cancer
Endoscopic US
Recent evidence suggests that EUS is similar to CT in diagnosis and staging of
pancreatic cancer. EUS requires special endoscopic skills and expertise, and it is
less readily available worldwide.
A 2.5cm round, hypoechoic
tumor is identified in the the
region of the genu. The
superior mesenteric vein can
be seen separate from the
tumor.
Invasion of the dilated CBD
by a large irregular
hypoechoic tumor located in
the head of pancreas.
A large hypoechoic tumor is seen to
invade the portal vein (arrow), with
loss of tumor-vessel interface and
tumor extension into vessel lumen.
The dilated CBD contains echogenic
sludge.

16. FNA for solid pancreatic mass
• All areas of pancreas including uncinate process and
tail, diameter >5mm
• Low complication rate ~ 1-2% (pancreatitis,
haemorrhage)
• ? Risk of peritoneal seeding
SensitivitySensitivity specificityspecificity PPVPPV NPVNPV
75-93%75-93% 95-100%95-100% 100%100% 25-85%25-85%
Vilmann, Wiresma, Giovannini, Chang, Gress, Bhutani, Hawes, Williams, Palazzo

17. Suspected pancreatic mass
Ultrasound
H-CT
No Mass
Mass
EUS +/- FNA
Bx (CT, EUS
or ERCP)
Palliation (biliary
stent/CPN,
oncology)
ERCP/Stent
Surgery
Cholangitis OR
delayed
resection +
jaundice/pruritu
s
Unresectabl
e
Resectable
Unresectable
Resectabl
e
Unresectabl
e

18. Dr Surendran: Is tissue diagnosis
required before surgery?

19. Surgery
• Laparotomy, locally advanced hard pancreatic mass-
uncinate (7cms) and body (5cms) of pancreas, encasing
SMA and SMV, hepatic artery and infiltrating serosa of
posterior stomach.
• Trial dissection, trucut biopsy of pancreatic tumours and
hepatic artery node excision done.
• Laparotomy, trial dissection, trucut biopsy of pancreatic
tumours and hepatic artery node excision done
• Dr Surendran’s comments:

20. Histopathology pictures

21. HISTOPATHOLOGY

22. HISTOPATHOLOGY

23. HISTOPATHOLOGY

24. HISTOPATHOLOGY

25. Histopathology
• Pancreatic core biopsies: chronic
inflammatory lesion with eosinophilia and
dense fibrosis, ductular proliferation and
granuloma-no malignancy
• Node- reactive inflammatory changes
• Dr Ashok Parameswaran’s comments:

26. Dr Rochita: Role of PET-CT in
pancreatic malignancy?

27. Questions
• Dr Anil Arora: What are the possibilities… DD
for inflammatory mass of pancreas?
• Dr Ramesh: Can this still be malignant mass?
How to proceed?

28. Two weeks later
• Yellowish discolouration of eyes
• Itching
• Palpable ill defined mass in epigastrium
• Bilirubin: 5mg/dl (Direct: 3.7 mg/dl)
• ALP:560 U/L
• ALT/AST: 78/60

29. • Dr Anil Arora: How to proceed?

30. • Dr Anil Arora: How to proceed?

31. CECT
ABDOMEN

32. CECT
ABDOMEN

36. Our case Case for comparison

37. • Dr Rochita’s comments

38. CECT abdomen
• The uncinate process of pancreas is enlarged. However, it
reveals normal enhancement in the venous phase. A similar
smaller area is seen in the mid body pancreas. The adjacent
main pancreatic duct is narrowed.In the tail and head of
pancreas, the main pancreatic duct is dilated. A rim of
hypodensity is seen around the lesion in the uncinate process
and body of pancreas. Peripancreatic fat planes are hazy
• Few small enhancing peripancreatic nodes are seen.
• The terminal common bile duct is compressed. Proximal to
this, the biliary tree is mildly dilated

39. CECT abdomen
• Enhancing soft tissue is seen along side the lesion in
body of pancreas and adherent to the common
hepatic artery
• IMPRESSION- CT findings could be suggestive of
autoimmune pancreatitis involving uncinate process
and body. The soft tissue along the body of pancreas
can be post operative changes.
– However, the possibility of an atypical neoplasm
cannot be ruled out. A close follow up would be
worthwhile.

40. Questions
• Dr Ramesh: What next? Diagnostic criteria for
autoimmune pancreatitis?

41. HISORt CRITERIA OF AIP
Category Criteria
A. Histology 1. Diagnostic (any one):
a) Pancreatic histology showing periductal lymphoplasmacytic
infiltrate with obliterative hlebitis (LPSP)
b) Lymphoplasmacytic infiltrate with abundant (>10 cells/hpf) IgG4
positive cells in the pancreas
2. Supportive (any one)
a) Lymphoplasmacytic infiltrate with abundant (>10 cells/hpf) IgG4
positive cells in involved extra-pancreatic organ
b) Lymphoplasmacytic infiltrate with fibrosis in the pancreas
B. Imaging Typical imaging features:
1. CT/MR: diffusely enlarged gland with delayed (rim) endhancement
2. ERCP: Diffusely irregular, attenuated main pancreatic duct
Atypical Imaging Features: Pancreatitis, focal pancreatic mass, focal
pancreatic duct stricture, pancreatic atrophy, pancreatic calcification
C. Serology Elevated serum IgG4 level (normal 8-140 mg/dl)
D. Other Organ
involvement
Hilar/intrahepatic biliary strictures, persistent distal biliary stricture,
Parotid/lacrimal gland involvement, Mediastinal lymphadenopathy,
Retroperitoneal fibrosis
E. Response to
steroid therapy
Resolution/marked improvement of pancreatic/extrapancreatic
manifestation with steroid therapy

42. CLINICAL DIAGNOSTIC CRITERIA FOR AIP
2006
1. Diffuse or segmental narrowing of the MPD with irregular
wall and diffuse or localized enlargement of the pancreas by
imaging studies, such as abdominal US, CT, and magnetic resonance
2. High serum γ-globulin, IgG, or IgG4, or the presence of
autoantibodies such as antinuclear antibodies and rheumatoid
factor
3. Marked interlobular fibrosis and prominent infiltration of
lymphocytes and plasma cells in the periductal area,
occasionally with lymphoid follicles in the pancreas
Diagnosis of AIP is established when criterion 1 and criterion 2
and/or 3 are fulfilled. However, it is necessary to exclude malignant
diseases.

43. AUTOIMMUNE PANCREATITIS
23,0% FOCAL FORM
(LIKE MALIGNANT LESION)
23,0% FOCAL FORM
(LIKE MALIGNANT LESION)
DIFFUSE FORM 77,0%
(LIKE ACUTE PANCREATITIS)
DIFFUSE FORM 77,0%
(LIKE ACUTE PANCREATITIS)

45. Dr Anil Arora: Sensitivity of Ig G4?

46. Dr Ashok Parameswaran:
Histological criteria for autoimmune
pancreatitis?

47. Histopathological Features of IgG4-
Related Disease-Type I AIP
(Predominantly Lobular)
1. Dense lymphoplasmacytic infiltrate
2. Fibrosis, arranged at least focally in a storiform pattern
3. Obliterative phlebitis
Consensus Statement on the Pathology of IgG4-Related Disease
Mod Pathol. 2012;25(9):1181-1192

48. Fibrosis, arranged in a storiform
pattern

49. Dense lymphoplasmacytic infiltrate

50. Obliterative phlebitis

51. Histopathological Features of Type II
AIP (Predominantly ductal)
• Periductal lymphoplasmacytic infiltrate
• Granulocytic epithelial lesion( Neutrophils in
ducts)
• Neutrophils within acini
• No storiform fibrosis
• No increased IgG4 plasma cells

52. 1.Presence of epithelioid granulomas
2.Prominent neutrophilic infiltrate
Consensus Statement on the Pathology of
IgG4-Related Disease
Mod Pathol. 2012;25(9):1181-1192
Histopathological Features
Inconsistent With a Diagnosis of IgG4-
Related Disease

53. Vikram Deshpande, Mari Mino-Kenudson, William Brugge, and Gregory Y. Lauwers
(2005) Autoimmune Pancreatitis: More Than Just a Pancreatic Disease?A
Contemporary Review of Its Pathology.
Archives of Pathology & Laboratory Medicine: September 2005, Vol. 129, No. 9, pp.
1148-1154.
• Epithelioid cell granulomas have been reported only rarely in
association with AIP. However, in a review of 19
pancreatectomy specimens we identified granulomas in 6
cases (32%). In 3 of these cases, granulomas were identified
in almost every section examined. In all cases, the granulomas
showed an exquisite ductocentric location The lack of nodal
involvement and the periductal distribution help exclude
pancreatic sarcoidosis and other granulomatous pathologies,
including mycobacterial infections.

54. Types of AIP
AIP TYPE I
Features of IgG4 disease
Older patients ( 70s)
Serum IgG4 increased
Tissue IgG4 positive
plasma cells
AIP TYPE II
No features of IgG4 disease
Younger patients ( 50s)
No Serum IgG4 increase
IgG4 positive plasma cells
not noted

55. • IgG4 : Elevated
• Started on steroids

56. Questions
• Dr Ramesh: What are the types of autoimmune
pancreatitis?
• Dr Rochita: Imaging features differentiating
autoimmune pancreatitis and malignancy.
• Dr Surendran: What proportion of Whipple’s surgery
specimen are autoimmune pancreatitis? Indian
experience?
• Dr Ashok Parameswaran: Histological findings in other
organs involved in IgG4 associated pancreatitis.
• Dr Anil Arora: What proportion of autoimmune
pancreatitis respond to steroids? Do they need
maintenance treatment? What is the relapse rate?

57. Types of autoimmune
pancreatitis

58. COMPARISON OF TYPE 1 AND TYPE 2 AIP
Type 1 AIP Type 2 AIP
Mean age Sixth decade Fourth decade
Gender distribution Predominantly male Equal
Histological pattern Lymphoplasmacytic
sclerosing pancreatitis
Duct-destructive
pancreatitis
Histological hallmarks Periductal
lymphoplasmacytic infiltrate
Swirling fibrosis
Obliterative venulitis
Lymphoplasmacyic infiltrate
Granulocyte epithelial lesion
with partial/complete duct
obstruction
IgG4 cells on
immunostaining
Moderate-severe (98%) Moderate (40%) in one
study
Serum IgG4 levels Elevated Normal
Other organ involvement Chronic sclerosing sialadenitis,
IgG4-associated cholangitis,
retroperitoneal fibrosis, IgG4-
associated tubulointerstitial
nephritis
Inflammatory bowel
disease
AIP,autoimmune pancreatitis, IgG4, immunoglobulin G4

59. CLINICAL PRESENTATIONS OF TYPE 1 AUTOIMMUNE PACREATITIS
Clinical presentations of type I AIP
Pancreatic Predominantly
extra-pancreatic
Biliary stricture,
sclerosing cholangitis
Interstitial nephritis,
renal failure
Retroperitoneal fibrosis
with complications
(e.g., ureteral obstruction)
Acute Post-acute/late
Obstructive
jaundice
Pancreatitis
Steatorrhea
Persistent
mass
Steatorrhea
Calcification,
atrophy
Park, D.H. 2009

60. Repeat CECT abdomen pictures
• Dr Rochita’s comments:

61. Follow up
• On review after 4 weeks, significant reduction
in size of pancreatic mass; jaundice resolved.
• Repeat CECT abdomen after 3 months, no
mass lesion noted.

62. THANK YOU