Pancreatic Cancer Masquerading as Pancreatitis

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1 Pancreatic Cancer Masquerading as Pancreatitis Poster No.: C-2553 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Cahalane, Y. M. Purcell, L. Lavelle, E. R. Ryan, S. Skehan ; Dublin, Dublin/IE, Dublin/IE Keywords: Neoplasia, Inflammation, Diagnostic procedure, MR, CT, Pancreas DOI: /ecr2015/C-2553 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 34

2 Learning objectives 1. To highlight the overlapping imaging features of pancreatic cancer and pancreatitis and the consequences of misdiagnosis. 2. To describe, with illustrated examples, the spectrum of mass-forming inflammatory processes that can mimic pancreatic adenocarcinoma. 3. To detail the distinguishing features that can assist in differentiating between the two processes. Background Pancreatic Cancer Pancreatic cancer (PCa) has an estimated incidence of 10.5 per 100,000 within the European Union Poor prognosis - overall 5 year survival of only 5% R0 resection remains the only potential curative treatment Only 15% of patients are resectable at diagnosis Misdiagnosis Up to 5% of PCa cases incorrectly diagnosed as pancreatitis Ultimate diagnosis can be delayed by several months Page 2 of 34

3 11% of resections for pancreatic cancer are ultimately benign processes, despite procedural morbidity of up to 40% and mortality of up to 9% Findings and procedure details Pancreatitis Mimickers of Pancreatic Cancer Acute pancreatitis (AP) Variable overall incidence 5-80/ M>F Main associations: alcohol excess & gallstones Acute and sudden pancreatic inflammation # 24% of cases progress to chronic pancreatitis Acute pancreatitis and pancreatic cancer PCa responsible for 1-2% of AP presentations 3% of PCa manifest as acute pancreatitis Can lead to delay in diagnosis of PCa of 8-12 months Chronic pancreatitis Overall incidence 4/100,000 Associated with recurrent episodes of pancreatic inflammation Irreversible parenchymal fibrosis and glandular atrophy Exocrine and endocrine dysfunction may result c. 50% associated with alcohol excess c. 25% may have pseudotumoural chronic pancreatitis Chronic pancreatitis and pancreatic cancer Chronic pancreatitis an independent risk factor for PCa Up to 5.7% of Whipple's Procedures performed for PCa have history of chronic pancreatitis [10] % benign histology Relative risk of developing PCa with chronic pancreatitis is 13.3% Page 3 of 34

4 Paraduodenal pancreatitis AKA: Cystic dystrophy of heterotopic pancreas, groove pancreatitis, paraduodenal wall cyst & myoadenomatosis Paraduodenal groove (PD) - Potential space between head of pancreas, duodenum & common bile duct Form of chronic pancreatitis with fibrotic scarring of PD Rare - incidence not established Men in their 40s Associated with alcohol excess Unclear pathogenesis 2 subtypes Pure form Groove only involved Sparing of pancreatic parenchyma & ducts Segmental form Involves groove & head of pancreas Pancreatic ductal stenosis Paraduodenal pancreatitis and pancreatic cancer Imaging distinction between paraduodenal pancreatitis & PCa is challenging, even with EUS Surgical resection sometimes required to outrule PCa, despite histology Autoimmune pancreatitis Benign autoimmune inflammatory process Rare - incidence < 1/100,000 2 subtypes Type 1 'IgG4-related disease' Manifestation of systemic autoimmune entity Lymphoplasmacytic sclerosing pancreatitis on histology with fibrosis & venulitis Average age at diagnosis yrs M>F Page 4 of 34

5 Elevated serum IgG4 & IgG4-positive cells on histology Extrapancreatic involvement Type 2 Restricted to pancreas Ductal granulocyte epithelial lesion on histology Average age at diagnosis yrs M=F Normal serum IgG4 Association with IBD (# 30% of patients) AIP and pancreatic cancer 2-3% of AIP cases mistakenly diagnosed with PCa prior to recognition of AIP as a separate entitity Focal pancreatic involvement with AIP (#41% of cases) can mimic PCa 70% of AIP cases correctly diagnosed with imaging, IgG4 serology & identification of extrapancreatic lesions Remainder may require ERCP/EUS biopsy +/- steroid trial Images for this section: Page 5 of 34

6 Fig. 1: Acute Pancreatitis Page 6 of 34

7 Fig. 2: Acute Pancreatitis Page 7 of 34

8 Fig. 3: Acute Pancreatitis Page 8 of 34

9 Fig. 4: Pancreaticoduodenal Groove Page 9 of 34

10 Fig. 5: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 10 of 34

11 Fig. 6: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 11 of 34

12 Fig. 7: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 12 of 34

13 Fig. 8: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 13 of 34

14 Fig. 9: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 14 of 34

15 Fig. 10: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 15 of 34

16 Fig. 11: Pancreatic Cancer in the Pancreaticoduodenal Groove Page 16 of 34

17 Fig. 12: Paraduodenal Pancreatitis Page 17 of 34

18 Fig. 13: Paraduodenal Pancreatitis Page 18 of 34

19 Fig. 14: Paraduodenal Pancreatitis Page 19 of 34

20 Fig. 15: Chronic Pancreatitis Page 20 of 34

21 Fig. 16: Chronic Pancreatitis Page 21 of 34

22 Fig. 17: Chronic Pancreatitis Page 22 of 34

23 Fig. 18: Chronic Pancreatitis Page 23 of 34

24 Fig. 19: Chronic Pancreatitis Page 24 of 34

25 Fig. 20: Chronic Pancreatitis Page 25 of 34

26 Fig. 21: Chronic Pancreatitis Page 26 of 34

27 Fig. 22: Autoimmune Pancreatitis Page 27 of 34

28 Fig. 23: Autoimmune Pancreatitis Page 28 of 34

29 Fig. 24: Autoimmune Pancreatitis Page 29 of 34

30 Fig. 25: Autoimmune Pancreatitis Page 30 of 34

31 Fig. 26: Autoimmune Pancreatitis Page 31 of 34

32 Conclusion A small percentage of cases of pancreatic cancer are misdiagnosed as varying forms of pancreatitis, making noninvasive definitive diagnosis difficult. Pancreatitis can also arise as a consequence of pancreatic adenocarcinoma. If the diagnosis is equivocal, preoperative tissue diagnosis should be pursued to avoid resection for benign processes. This exhibit has classified these differential diagnoses and provides illustrated examples to assist in distinguishing between them. Personal information Dr. Alexis Cahalane, Specialist Registrar in Radiology, St. Vincent's University Hospital, Dublin, Ireland. Dr. Yvonne M. Purcell, Specialist Registrar in Radiology, St. Vincent's University Hospital, Dublin, Ireland. Dr. Lisa Lavelle, Abdominal Radiology Fellow, St. Vincent's University Hospital, Dublin, Ireland. Dr. E. Ronan Ryan, Consultant Abdominal Diagnostic and Interventional Radiologist, St. Vincent's University Hospital, Dublin, Ireland. Dr. Stephen Skehan, Consultant Radiologist in Hepatobiliary and GI Imaging, St. Vincent's University Hospital, Dublin, Ireland. References 1. Ferlay, J., et al., Cancer incidence and mortality patterns in Europe: estimates for 40 countries in Eur J Cancer, (6): p Page 32 of 34

33 2. Frampas, E., et al., A solid pancreatic mass: tumour or inflammation? Diagn Interv Imaging, (7-8): p Ryan, D.P., T.S. Hong, and N. Bardeesy, Pancreatic adenocarcinoma. N Engl J Med, (11): p Konstantinidis, I.T., et al., Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a "true" R0 resection? Ann Surg, (4): p Munigala, S., et al., New diagnosis of chronic pancreatitis: risk of missing an underlying pancreatic cancer. Am J Gastroenterol, (11): p Muscari, F., et al., Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients. Surgery, (5): p Sekimoto, M., et al., JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J Hepatobiliary Pancreat Surg, (1): p Al-Hawary, M.M., et al., Mimics of pancreatic ductal adenocarcinoma. Cancer Imaging, (3): p Tellez-Avila, F.I., et al., Follow-up of patients with pseudotumoral chronic pancreatitis: outcome and surveillance. World J Gastroenterol, (26): p Merdrignac, A., et al., Pancreatic head cancer in patients with chronic pancreatitis. Hepatobiliary Pancreat Dis Int, (2): p Levenick, J.M., et al., A comprehensive, case-based review of groove pancreatitis. Pancreas, (6): p. e Malde, D.J., M. Oliveira-Cunha, and A.M. Smith, Pancreatic carcinoma masquerading as groove pancreatitis: case report and review of literature. Jop, (6): p Page 33 of 34

34 13. Morse, B., B. Centeno, and S. Vignesh, Autoimmune pancreatitis: updated concepts of a challenging diagnosis. Am J Med, (10): p e Ketwaroo, G.A. and S. Sheth, Autoimmune pancreatitis. Gastroenterol Rep (Oxf), (1): p Shimosegawa, T., et al., International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas, (3): p Chari, S.T., et al., A diagnostic strategy to distinguish autoimmune pancreatitis from pancreatic cancer. Clin Gastroenterol Hepatol, (10): p Page 34 of 34

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