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Unusual Cause of Hematochezia
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Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
Unusual Cause of Hematochezia Q1
Natally Horvat,1,2,3 Serena Monti,4 and Lorenzo Mannelli1 1 Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York; 2Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil; 3Department of Radiology, Universidade de São Paulo, Dr. Enéas de Carvalho Aguiar, São Paulo, Brazil; and 4IRCCS SDN, Naples, Italy
Question: A 73-year-old woman experienced 2 episodes of hematochezia 2 weeks before her admission. She had been treated for mild hypertension, and had a history of cholecystectomy, appendectomy, 2 C-sections, and unspecified pancreatic surgery 17 years prior. At presentation, her laboratory examinations showed a mild anemia (hemoglobin, 10.7 g/dL; hematocrit, 33.5%) and a slight increase of alkaline phosphatase (169 U/L; normal range, 45-129). She underwent colonoscopy at an outside hospital, which demonstrated an ulcerated partially obstructing large mass in the right colon. A contrastenhanced computed tomography (CT) scan was subsequently requested in our hospital. Contrast-enhanced CT scan showed an 18.0 17.0-cm large pancreatic multilobulated cystic mass in the head of the pancreas with innumerable central calcifications (Figure A). CT images also demonstrated that the mass was composed of numinous central small cysts and some peripheral larger cysts (Figures A, white asterisks). The pancreatic mass was associated with pancreatic atrophy, biliary and pancreatic ducts dilatation (Figures A, black asterisks), encased the superior mesenteric vein (Figure A, black arrow), and displaced the duodenum (Figure A, white arrows). The pancreatic mass also infiltrated and protruded into the right colon lumen (Figure A, dashed arrows). What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI.
Conflicts of interest The authors disclose no conflicts. Funding This work was supported by the MSK Cancer Center Support Grant/Core Grant P30 CA008748. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2017.01.007
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CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 1 (page ---): Giant Serous Cystadenoma of the Pancreas Infiltrating the Colonic Wall
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CT and magnetic resonance imaging studies obtained at the time of the patient described 17 years prior pancreatic surgery were obtained. These demonstrated an 8.5 8.0-cm typical serous cystadenoma with a honeycomb appearance on T2-weighted imaging (Figure B) and encasing the superior mesenteric vein (Figure C, black arrow). The operating room report back then described that the resection of the pancreatic lesion was not possible owing to adhesion to the superior mesenteric vein. The patient underwent right hemicolectomy and debulking of the serous cystadenoma because its complete resection was not possible. Pathology confirmed the diagnosis of serous cystadenoma infiltrating the colonic wall (Figure D). Microscopy showed variably sized small cysts lined by cuboidal cells with small hyperchromatic nuclei and subepithelial capillaries (Figure E; stain: hematoxylin and eosin; original magnification, 100). Pancreatic serous cystadenoma is a benign neoplasm which accounts for 1%-2% of all primary pancreatic neoplasms and 10%-15% of cystic pancreatic lesions.1 However, giant pancreatic serous cystadenomas (GPSC), defined as lesions measuring 10 cm, are very rare with only some sporadic cases reported in the literature.2 Liu et al2 in a recent review demonstrated that GPSC was more common in women (76%), with a mean age of 65.5 years and slightly more frequent in the head of the pancreas (59%). GPSC tend to adhere, compress, encase, or even infiltrate adjacent structures. Therefore, symptoms are more frequent, occurring in around 70% of cases, such as abdominal pain, nausea, vomiting, and abdominal mass. The microcystic appearance is more frequent (59%), followed by the macrocystic (35%) and mixed type (6%). Some surgeons advocate surgical resection for serous cystadenomas measuring 4 cm owing to rapid growth and potential complications, including obstructive pancreatitis, infiltration of surrounding structures, and malignant transformation.3 Curative resection is the treatment of choice for GPSC, when feasible.
References 1. 2. 3.
Bosman FT, Carneiro F, Hruban RH, et al. WHO classification of tumours of the digestive system. Geneva: World Health Organization; 2010. Liu QY, Zhou J, Zeng YR, et al. Giant serous cystadenoma of the pancreas ( 10 cm): the clinical features and CT findings. Gastroenterol Res Pract 2016;2016:8454823. Horvat N, Monti S, Mannelli L. Unusual liver tumors. Gastroenterology 2017;152:1287–1288.
For submission instructions, please see the Gastroenterology website (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60912 proof 2 June 2017 4:14 pm ce
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Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
Unusual Cause of Hematochezia Q1
Natally Horvat,1,2,3 Serena Monti,4 and Lorenzo Mannelli1 1 Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York; 2Department of Radiology, Hospital Sírio-Libanês, São Paulo, Brazil; 3Department of Radiology, Universidade de São Paulo, Dr. Enéas de Carvalho Aguiar, São Paulo, Brazil; and 4IRCCS SDN, Naples, Italy
Question: A 73-year-old woman experienced 2 episodes of hematochezia 2 weeks before her admission. She had been treated for mild hypertension, and had a history of cholecystectomy, appendectomy, 2 C-sections, and unspecified pancreatic surgery 17 years prior. At presentation, her laboratory examinations showed a mild anemia (hemoglobin, 10.7 g/dL; hematocrit, 33.5%) and a slight increase of alkaline phosphatase (169 U/L; normal range, 45-129). She underwent colonoscopy at an outside hospital, which demonstrated an ulcerated partially obstructing large mass in the right colon. A contrastenhanced computed tomography (CT) scan was subsequently requested in our hospital. Contrast-enhanced CT scan showed an 18.0 17.0-cm large pancreatic multilobulated cystic mass in the head of the pancreas with innumerable central calcifications (Figure A). CT images also demonstrated that the mass was composed of numinous central small cysts and some peripheral larger cysts (Figures A, white asterisks). The pancreatic mass was associated with pancreatic atrophy, biliary and pancreatic ducts dilatation (Figures A, black asterisks), encased the superior mesenteric vein (Figure A, black arrow), and displaced the duodenum (Figure A, white arrows). The pancreatic mass also infiltrated and protruded into the right colon lumen (Figure A, dashed arrows). What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI.
Conflicts of interest The authors disclose no conflicts. Funding This work was supported by the MSK Cancer Center Support Grant/Core Grant P30 CA008748. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2017.01.007
Gastroenterology 2017;-:1–2 DIS 5.4.0 DTD YGAST60912 proof 2 June 2017 4:13 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 1 (page ---): Giant Serous Cystadenoma of the Pancreas Infiltrating the Colonic Wall
print & web 4C=FPO
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
CT and magnetic resonance imaging studies obtained at the time of the patient described 17 years prior pancreatic surgery were obtained. These demonstrated an 8.5 8.0-cm typical serous cystadenoma with a honeycomb appearance on T2-weighted imaging (Figure B) and encasing the superior mesenteric vein (Figure C, black arrow). The operating room report back then described that the resection of the pancreatic lesion was not possible owing to adhesion to the superior mesenteric vein. The patient underwent right hemicolectomy and debulking of the serous cystadenoma because its complete resection was not possible. Pathology confirmed the diagnosis of serous cystadenoma infiltrating the colonic wall (Figure D). Microscopy showed variably sized small cysts lined by cuboidal cells with small hyperchromatic nuclei and subepithelial capillaries (Figure E; stain: hematoxylin and eosin; original magnification, 100). Pancreatic serous cystadenoma is a benign neoplasm which accounts for 1%-2% of all primary pancreatic neoplasms and 10%-15% of cystic pancreatic lesions.1 However, giant pancreatic serous cystadenomas (GPSC), defined as lesions measuring 10 cm, are very rare with only some sporadic cases reported in the literature.2 Liu et al2 in a recent review demonstrated that GPSC was more common in women (76%), with a mean age of 65.5 years and slightly more frequent in the head of the pancreas (59%). GPSC tend to adhere, compress, encase, or even infiltrate adjacent structures. Therefore, symptoms are more frequent, occurring in around 70% of cases, such as abdominal pain, nausea, vomiting, and abdominal mass. The microcystic appearance is more frequent (59%), followed by the macrocystic (35%) and mixed type (6%). Some surgeons advocate surgical resection for serous cystadenomas measuring 4 cm owing to rapid growth and potential complications, including obstructive pancreatitis, infiltration of surrounding structures, and malignant transformation.3 Curative resection is the treatment of choice for GPSC, when feasible.
References 1. 2. 3.
Bosman FT, Carneiro F, Hruban RH, et al. WHO classification of tumours of the digestive system. Geneva: World Health Organization; 2010. Liu QY, Zhou J, Zeng YR, et al. Giant serous cystadenoma of the pancreas ( 10 cm): the clinical features and CT findings. Gastroenterol Res Pract 2016;2016:8454823. Horvat N, Monti S, Mannelli L. Unusual liver tumors. Gastroenterology 2017;152:1287–1288.
For submission instructions, please see the Gastroenterology website (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60912 proof 2 June 2017 4:14 pm ce
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