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Clinical Challenges and Images in GI

2006; Elsevier BV; Volume: 131; Issue: 2 Linguagem: Inglês

10.1053/j.gastro.2005.11.067

1528-0012

Samuel Davidoff, Angelo Fernandes, Kostas Sideridis, Gary Gecelter, Jeremy Bragdon, Simmy Bank,

Hepatocellular Carcinoma Treatment and Prognosis

Question: A 66-year-old white man presented with episodic abdominal pain for 6 months. He also complained of occasional bloating and watery diarrhea. He denied any weight loss, nausea, vomiting, or change in appetite. His past medical history was significant for hypertension and anxiety disorder. His medications included lorazepam, hydrochlorothiazide, and irbesartan. He has a negative family history for gastrointestinal malignancies. An abdominal ultrasound revealed a poorly visualized mass in the midepigastric region. A computerized tomography (CT) scan of the abdomen was done (Figure A). Complete blood count, metabolic panel, and coagulation profile were within normal limits. Special serum chemistries, including 24-hour 5-hydroxyindoleacetic acid (5HIAA), fasting gastrin, C-peptide, glucagon, pancreatic polypeptide, serotonin, and chromogranin A were all within normal limits. The patient was then sent for an Indium-111 Pentetreotide (Octreoscan) (Figure B), which showed a discrete focus of increased activity in the abdomen on delayed SPECT imaging at 72 hours after injection.View Large Image Figure ViewerDownload (PPT)What is his diagnosis? What is the proper treatment?Look on page 689 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.Answer to the Clinical Challenges and Images in GI Question 1 (page 350): Intrapancreatic Accessory Spleen Mimicking Nonfunctioning Neuroendocrine TumorThe CT scan showed a hypervascular 1.6-cm mass in the tail of the pancreas. Increased uptake in the mass was noted on the octreoscan raising a question of a nonfunctioning neuroendocrine tumor. The risks and benefits of surgical intervention versus further diagnostic work up (EUS with biopsy) were discussed with the patient and he elected to proceed with surgical resection of the mass. A laparoscopic spleen saving distal pancreatectomy was performed. Intraoperative ultrasound localized the lesion as a hyperechoic area, thereby denoting the proximal extent of dissection. Gross section performed in the operating room showed the cut surface of the lesion was dark and well demarcated, relative to the pancreatic parenchyma (Figure C). Microscopic examination showed pancreatic tissue adjacent to spplenic tissue (Figure D). A diagnosis of an intrapancreatic accessory spleen (IPAS) was made. The patient was discharged 3 days after the surgery and at 6 months’ follow-up is doing well with no major complaints.View Large Image Figure ViewerDownload (PPT)View Large Image Figure ViewerDownload (PPT)Accessory spleens occur in approximately 10% of the population. In a large autopsy series, 80% of these were located at or near the splenic hilum.1Halpert B. Gyorkey F. Lesions observed in accessory spleens of 311 patients.J Clin Pathol. 1959; 32: 165-168Google Scholar The pancreatic tail was the second most common location, with 16% (61 of 364) of the accessory spleens.1Halpert B. Gyorkey F. Lesions observed in accessory spleens of 311 patients.J Clin Pathol. 1959; 32: 165-168Google Scholar Accessory spleens range in size from a few millimeters to several centimeters and can be single or multiple. They are almost always aymptomatic incidental findings. If IPAS are large enough, they can be picked up as a solid enhancing mass on routine CT of the abdomen. Differential diagnosis at that point would include solid and papillary epithelial neoplasms, islet cell tumors, pancreatic adenocarcinomas, neuroendocrine tumors, or metastases. Although routine MRI or US are similarly unable to distinguish IPAS from tumor, scintigraphy with Technetium 99m sulfur colloid scan is more specific.2White D.J. West A.N. Splenosis mimicking an intra-abdominal malignancy.Am J Med. 1989; 87: 687-690Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 3Chung S.Y. Ryo Y. Pinsky S. Evaluation of a patient with splenosis by various imaging modalities.J Natl Med Assoc. 1986; 78: 458-463PubMed Google Scholar Radiolabeled heat-damaged red blood cells and Indium 111-labeled autologous platelets are more time consuming but may demonstrate lesions not depicted by the Technetium 99m sulfur colloid scan.2White D.J. West A.N. Splenosis mimicking an intra-abdominal malignancy.Am J Med. 1989; 87: 687-690Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 4Bidet A.C. Dreyfus-Schmidt G. Mas J. Diagnosis of splenosis the advantage of splenic scintiscanning with Tc 99m heat-damaged red blood cells.Eur J Nucl Med. 1986; 12: 357-358Crossref PubMed Scopus (39) Google ScholarThe case presented here illustrates how incidental IPAS can be mistaken for neuroendocrine tumors. Octreotide scanning will be misleading in these cases secondary to normal physiologic uptake in splenic tissue.3Chung S.Y. Ryo Y. Pinsky S. Evaluation of a patient with splenosis by various imaging modalities.J Natl Med Assoc. 1986; 78: 458-463PubMed Google Scholar Caution should be used when IPAS is a consideration, and scintigraphy with labeled sulfur colloid or damaged RBCs, or EUS with Bx, should be performed before surgery.Our patient’s apparent clinical response to surgery may have been due to the placebo effect. Question: A 66-year-old white man presented with episodic abdominal pain for 6 months. He also complained of occasional bloating and watery diarrhea. He denied any weight loss, nausea, vomiting, or change in appetite. His past medical history was significant for hypertension and anxiety disorder. His medications included lorazepam, hydrochlorothiazide, and irbesartan. He has a negative family history for gastrointestinal malignancies. An abdominal ultrasound revealed a poorly visualized mass in the midepigastric region. A computerized tomography (CT) scan of the abdomen was done (Figure A). Complete blood count, metabolic panel, and coagulation profile were within normal limits. Special serum chemistries, including 24-hour 5-hydroxyindoleacetic acid (5HIAA), fasting gastrin, C-peptide, glucagon, pancreatic polypeptide, serotonin, and chromogranin A were all within normal limits. The patient was then sent for an Indium-111 Pentetreotide (Octreoscan) (Figure B), which showed a discrete focus of increased activity in the abdomen on delayed SPECT imaging at 72 hours after injection. What is his diagnosis? What is the proper treatment? Look on page 689 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Answer to the Clinical Challenges and Images in GI Question 1 (page 350): Intrapancreatic Accessory Spleen Mimicking Nonfunctioning Neuroendocrine TumorThe CT scan showed a hypervascular 1.6-cm mass in the tail of the pancreas. Increased uptake in the mass was noted on the octreoscan raising a question of a nonfunctioning neuroendocrine tumor. The risks and benefits of surgical intervention versus further diagnostic work up (EUS with biopsy) were discussed with the patient and he elected to proceed with surgical resection of the mass. A laparoscopic spleen saving distal pancreatectomy was performed. Intraoperative ultrasound localized the lesion as a hyperechoic area, thereby denoting the proximal extent of dissection. Gross section performed in the operating room showed the cut surface of the lesion was dark and well demarcated, relative to the pancreatic parenchyma (Figure C). Microscopic examination showed pancreatic tissue adjacent to spplenic tissue (Figure D). A diagnosis of an intrapancreatic accessory spleen (IPAS) was made. The patient was discharged 3 days after the surgery and at 6 months’ follow-up is doing well with no major complaints.View Large Image Figure ViewerDownload (PPT)Accessory spleens occur in approximately 10% of the population. In a large autopsy series, 80% of these were located at or near the splenic hilum.1Halpert B. Gyorkey F. Lesions observed in accessory spleens of 311 patients.J Clin Pathol. 1959; 32: 165-168Google Scholar The pancreatic tail was the second most common location, with 16% (61 of 364) of the accessory spleens.1Halpert B. Gyorkey F. Lesions observed in accessory spleens of 311 patients.J Clin Pathol. 1959; 32: 165-168Google Scholar Accessory spleens range in size from a few millimeters to several centimeters and can be single or multiple. They are almost always aymptomatic incidental findings. If IPAS are large enough, they can be picked up as a solid enhancing mass on routine CT of the abdomen. Differential diagnosis at that point would include solid and papillary epithelial neoplasms, islet cell tumors, pancreatic adenocarcinomas, neuroendocrine tumors, or metastases. Although routine MRI or US are similarly unable to distinguish IPAS from tumor, scintigraphy with Technetium 99m sulfur colloid scan is more specific.2White D.J. West A.N. Splenosis mimicking an intra-abdominal malignancy.Am J Med. 1989; 87: 687-690Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 3Chung S.Y. Ryo Y. Pinsky S. Evaluation of a patient with splenosis by various imaging modalities.J Natl Med Assoc. 1986; 78: 458-463PubMed Google Scholar Radiolabeled heat-damaged red blood cells and Indium 111-labeled autologous platelets are more time consuming but may demonstrate lesions not depicted by the Technetium 99m sulfur colloid scan.2White D.J. West A.N. Splenosis mimicking an intra-abdominal malignancy.Am J Med. 1989; 87: 687-690Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 4Bidet A.C. Dreyfus-Schmidt G. Mas J. Diagnosis of splenosis the advantage of splenic scintiscanning with Tc 99m heat-damaged red blood cells.Eur J Nucl Med. 1986; 12: 357-358Crossref PubMed Scopus (39) Google ScholarThe case presented here illustrates how incidental IPAS can be mistaken for neuroendocrine tumors. Octreotide scanning will be misleading in these cases secondary to normal physiologic uptake in splenic tissue.3Chung S.Y. Ryo Y. Pinsky S. Evaluation of a patient with splenosis by various imaging modalities.J Natl Med Assoc. 1986; 78: 458-463PubMed Google Scholar Caution should be used when IPAS is a consideration, and scintigraphy with labeled sulfur colloid or damaged RBCs, or EUS with Bx, should be performed before surgery.Our patient’s apparent clinical response to surgery may have been due to the placebo effect. The CT scan showed a hypervascular 1.6-cm mass in the tail of the pancreas. Increased uptake in the mass was noted on the octreoscan raising a question of a nonfunctioning neuroendocrine tumor. The risks and benefits of surgical intervention versus further diagnostic work up (EUS with biopsy) were discussed with the patient and he elected to proceed with surgical resection of the mass. A laparoscopic spleen saving distal pancreatectomy was performed. Intraoperative ultrasound localized the lesion as a hyperechoic area, thereby denoting the proximal extent of dissection. Gross section performed in the operating room showed the cut surface of the lesion was dark and well demarcated, relative to the pancreatic parenchyma (Figure C). Microscopic examination showed pancreatic tissue adjacent to spplenic tissue (Figure D). A diagnosis of an intrapancreatic accessory spleen (IPAS) was made. The patient was discharged 3 days after the surgery and at 6 months’ follow-up is doing well with no major complaints. Accessory spleens occur in approximately 10% of the population. In a large autopsy series, 80% of these were located at or near the splenic hilum.1Halpert B. Gyorkey F. Lesions observed in accessory spleens of 311 patients.J Clin Pathol. 1959; 32: 165-168Google Scholar The pancreatic tail was the second most common location, with 16% (61 of 364) of the accessory spleens.1Halpert B. Gyorkey F. Lesions observed in accessory spleens of 311 patients.J Clin Pathol. 1959; 32: 165-168Google Scholar Accessory spleens range in size from a few millimeters to several centimeters and can be single or multiple. They are almost always aymptomatic incidental findings. If IPAS are large enough, they can be picked up as a solid enhancing mass on routine CT of the abdomen. Differential diagnosis at that point would include solid and papillary epithelial neoplasms, islet cell tumors, pancreatic adenocarcinomas, neuroendocrine tumors, or metastases. Although routine MRI or US are similarly unable to distinguish IPAS from tumor, scintigraphy with Technetium 99m sulfur colloid scan is more specific.2White D.J. West A.N. Splenosis mimicking an intra-abdominal malignancy.Am J Med. 1989; 87: 687-690Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 3Chung S.Y. Ryo Y. Pinsky S. Evaluation of a patient with splenosis by various imaging modalities.J Natl Med Assoc. 1986; 78: 458-463PubMed Google Scholar Radiolabeled heat-damaged red blood cells and Indium 111-labeled autologous platelets are more time consuming but may demonstrate lesions not depicted by the Technetium 99m sulfur colloid scan.2White D.J. West A.N. Splenosis mimicking an intra-abdominal malignancy.Am J Med. 1989; 87: 687-690Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 4Bidet A.C. Dreyfus-Schmidt G. Mas J. Diagnosis of splenosis the advantage of splenic scintiscanning with Tc 99m heat-damaged red blood cells.Eur J Nucl Med. 1986; 12: 357-358Crossref PubMed Scopus (39) Google Scholar The case presented here illustrates how incidental IPAS can be mistaken for neuroendocrine tumors. Octreotide scanning will be misleading in these cases secondary to normal physiologic uptake in splenic tissue.3Chung S.Y. Ryo Y. Pinsky S. Evaluation of a patient with splenosis by various imaging modalities.J Natl Med Assoc. 1986; 78: 458-463PubMed Google Scholar Caution should be used when IPAS is a consideration, and scintigraphy with labeled sulfur colloid or damaged RBCs, or EUS with Bx, should be performed before surgery. Our patient’s apparent clinical response to surgery may have been due to the placebo effect.