Solid-Pseudopapillärer Pankreastumor als sonographisches Inzidentalom bei akuter phlegmonöser Appendizitis

Zusammenfassung

Kasus: ♀ 21 J, Vorstellung wegen akuter phlegmonöser Appendizitis mit akutem Unterbauchschmerz und Übelkeit. Gleiche Symptomatik seit einem Jahr, allmonatlich rekurrierend, mit Spontanremission nach 2-4 Tagen. Erhöhung der Entzündungsparameter, Kokardenphänomen in der Sonographie. Nebenbefundlich, sonographisch: ca. 6 cm im Durchmesser fassender Tumor, im CT als zystisch-solide Raumforderung imponierend. OP: 1. laparoskopisch beginnend, Umstieg auf offene Appendektomie bei intraoperativ eitrig-phlegmonösem Bild. 2. Pankreaslinksresektion mit Splenektomie im Intervall (10. postoperativer Tag). Histologie: Solid-Pseudopapillärer Pankreastumor. Postoperativer Verlauf komplikationslos. - Vier Jahre nach Operation befindet sich die Patientin beschwerdefrei, bei physiologischer exo- und endokriner Pankreasfunktion. Schlussfolgerung: Auch bei eindeutigem sonographischem Befund, z. B. i. R. e. akuten Appendizitis mit Kokardenphänomen, freier intraabdomineller Flüssigkeit etc., sollte das gesamte Abdomen im Hinblick auf weitere auffällige Befunde sorgfältig evaluiert werden. Rekurrente Abdominalbeschwerden bedürfen der diagnostisch abklärenden Aufmerksamkeit.

Abstract

Objective: Review of the literature (Medline) based on a clinical case. Case: A twenty one year old lady presented with a one day history of acute right sided lower abdominal pain associated with leucocytosis and the clinical signs of an acute abdomen. Sonography showed fluid coincident with cocardal formation in the right lower abdomen. Incidentally a cystic formation in projection to the caudal pancreas was seen. A CT scan confirmed a cystic mass, 5 cm in diameter. An appendectomy was performed immediately after admission. After an interval of ten days an upper laparotomy leading to a left sided resection of the pancreas was performed. Histological findings showed a solid-pseudo-papillary tumor of the pancreas without any signs of metastatic spreading. Four years after the operation the patient is subjectively well and shows no signs of diabetes or of insufficiency of the exocrine pancreas nor of any recurrence. - Characteristic findings in solid-pseudo-papillary pancreatic tumors (SPPT) are remarkable size at the time of diagnosis, low risk of malignancy, predominance in young female (10 ♀ : 1 ♂, M = 27 a), association with oral anticonceptive drugs and mostly incidentally detection. Usually the definitive diagnosis is only found after complete radical resection which in 95 % of cases is curative. Conclusion: Abdominal sonography should be performed very thoroughly in any diagnostic query even if, clinically, the diagnosis seems to be obvious.

solid-pseudopapillärer Pankreastumor (SPPT) - akutes Abdomen - akute Appendizitis - Inzidentalom

solid-pseudo-papillary pancreatic tumor (SPPT) - incidentaloma - acute abdomen - acute appendicitis

Literatur

• 1 Adair C F, Wenig B M, Heffes C S. Solid and papillary cystic carcinoma of the pancreas: A tumor of low malignant potential.  Int J Surg Pathol. 1995;  2 326-236
• 2 Balercia G, Zamboni G, Bogina G. et al . Solid-cystic tumor of the pancreas. An extensive ultrastructural study of fourteen cases.  J Submicrosc Cytol Pathol. 1995;  27 331-340
• 3 Bhutani M S. Role of endoscopic ultrasonography in the diagnosis and treatment of cystic tumors of the pancreas.  JOP. 2004;  5 266-272
• 4 Buetow P C, Buck J L, Pantongrag-Brown L. et al . Solid and papillary epitelial neoplasm of the pancreas: Imaging-pathologic correlation on 56 cases.  Radiology. 1996;  199 707-711
• 5 Chott A, Kloppel G, Buxbaum P. et al . Neuron specific enolase demonstration in the diagnosis of a solid-cystic (papillary cystic) tumor of the pancreas.  Virchows Arch A Pathol Anat Histopathol. 1987;  410 397-402
• 6 Dong P R, Lu D S, Degregario F. et al . Solid and papillary neoplasm of the pancreas: radiological and pathological study of five cases and review of the literature.  Clin Radiol. 1996;  51 702-705
• 7 Duff P, Greene V P. Pregnancy is complicated by solid-papillary epithelial tumor of the pancreas, pulmonary embolism, and pulmonary embolectomy.  Am J Obstet Gynecol. 1985;  152 80-81
• 8 Fitzgerald T L, Smith A J, Ryan M. et al . Surgical treatment of incidentally identified pancreatic masses.  Can J Surg. 2003;  46 413-418
• 9 Hansson B, Hubens G, Hagendorens M. et al . Fantz' tumor of the pancreas presenting as a post-traumatic pancreatic pseudocyst.  Acta Chir Belg. 1999;  99 82-84
• 10 Jeng L B, Chen M F, Tang R P. Solid and papillary enoplasm of the pancreas. Emphasis on surgical treatment.  Arch Surg. 1993;  128 433-436
• 11 Kashima K, Hayashida Y, Yokoyama S. et al . Cytologic features of solid and cystic tumor of the pancreas.  Acta Cytol. 1997;  41 443-449
• 12 Klimstra D S, Wenig B M, Hefess C S. Solid-pseudopapillary tumor of the pancreas: a typically cystic carcinoma of low malignant potential.  Semin Diagn Pathol. 2000;  17 66-80
• 13 Kobayashi T, Kimura T, Takabayashi N. et al . Two synchronous solid and cystic tumors of the pancreas.  J Gastroenterol. 1998;  33 439-442
• 14 Ladanyi M, Mulay S, Arseneau J. et al . Estrogen and progesterone receptor determination in the papillary cystic neoplasm of the pancreas. With immunhistochemical and ultrastructural observations.  Cancer. 1987;  60 1604-1611
• 15 Matsuno H, Konishi F. Papillary-cystic neoplasm of the pancreas. A clinicopathologic study concerning the tumor aging and malignancy of nine cases.  Cancer. 1990;  65 283-291
• 16 Matsunou H, Konishi F, Yamamichi N. et al . Solid infiltrating variety of papillary cystic neoplasm of the pancreas.  Cancer. 1990;  65 2747-2757
• 17 Miao F, Zhan Y, Wang X Y. et al . CT manifestations and features of solid cystic tumors of the pancreas.  Hepatobiliary Pancreat Dis Int. 2002;  1 465-468
• 18 Ogawa T, Isaji S, Okamura K. et al . A case of radical resection for solid cystic tumor of the pancreas with widespread metastases in the liver and greater omentum.  Am J Gastroenterol. 1993;  88 1436-1439
• 19 Pelosi G, Ianucci A, Zamboni G. et al . Solid and cystic papillary neoplasm of the pancreas: A clinico-cytopathologic and immunocytochemical study of five new cases diagnosed by fine-needle aspiration cytology and a review of the literature.  Diagn Cytopathol. 1995;  13 233-246
• 20 Persson M, Bisgaard C, Nielsen B B. et al . Solid and papillary epithelial neoplasm of the pancreas presenting as a traumatic cyst. Case report.  Acta Chir Scand. 1986;  152 223-226
• 21 Pettinato G, Manivel J C, Ravetto C. et al . Papillary cystic tumor of the pancreas. A clinicopathologic study of 20 cases with cytologic, immunhistochemical, ultrastructural and flow cytometric observations and a review of the literature.  Am J Clin Pathol. 1992;  98 478-488 ,  Am J Clin Pathol 1993, 99: 764
• 22 Piatek S, Manger T, Rose I, Schulz H U, Lippert H. Solid pseudopapillary tumor of the pancreas.  Int J Pancreatol. 2000;  27 77-81
• 23 Raffel A, Cupisti K, Krausch M. et al . Therapeutic strategy of papillary cystic and solid neoplasm (PCSN): a rare non-endocrine tumor of the pancreas in children.  Surg Oncol. 2004;  13 1-6
• 24 Salvia R, Festa L, Butturini G. et al . Pancreatic cystic tumors.  Minerva Chir. 2004;  59 185-207
• 25 Savci G, Kilicturgay S, Sivri Z. et al . Solid and papillary epithelial neoplasm of the pancreas: CT and MR findings.  Eur Radiol. 1996;  6 86-88
• 26 Sclafani L M, Reuter V E, Coit D G. et al . The malignant nature of papillary and cystic neoplasm of the pancreas.  Cancer. 1991;  68 153-158
• 27 Spinelli K S, Fromwiller T E, Daniel R A. et al . Cystic pancreatic neoplasms:observe or operate.  Ann Surg. 2004;  239 651-657
• 28 Stommer P, Kraus J, Stolte M. et al . Solid and cystic pancreatic tumors. Clinical, histochemical and electron microscopic features in ten cases.  Cancer. 1991;  67 1635-1641
• 29 Wilson M B, Adams D B, Garen P D. et al . Aspiration cytologic, ultrastructural and DNA cytometric findings of solid and papillary tumor of the pancreas.  Cancer. 1992;  69 2235-2243
• 30 Zamboni G, Bonetti F, Scarpa A. et al . Expression of the progesterone receptors in solid-cystic tumor of the pancreas: A clinicopathological and immunhistochemical study of ten cases.  Virchows Arch A Pathol Anat Histopathol. 1993;  423 425-431