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Endoscopic ultrasonography allowing expectant management of pancreatic haemangioma

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Abstract

Pancreatic haemangiomas are rare benign tumours that can affect both adults and children. They have an unknown incidence and only 15 adult cases have been reported, all from histological examination. Patients present with vague symptoms relating to tumour mass or they are detected incidentally. Cross-sectional imaging is the mainstay of investigation and may reveal arterially enhancing cystic lesions but in the case presented here, it was non-diagnostic. The use of endoscopic ultrasonography confirmed the nature of the benign lesion, allowing a conservative approach as opposed to operative resection.

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... A PubMed and Google Scholar search of the literature using the keywords "pancreas hemangioma" was performed, and pertinent articles and their references were reviewed. Since 1960, a total of twenty-one cases have been reported in nineteen articles (Table 1) [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] . Mundinger et al [20] in their 2009 article, stated that a number of nine cases have been described in the medical literature prior to 1939. ...
... A non-enhancing three-phase contrast CT scan does not exclude hemangioma. Of the cases that reported pre-contrast CT findings, five lesions (No. 8,9,11,17,19) were heterogeneous (with both, high and low attenuation), multi-loculated cysts and five (No. 13,14,16,18,20) were hypo-attenuating "cysts" with solid components and peripheral micro-or speckled calcifications. Postcontrast CT showed poorly enhanced or unenhanced, hypo-vascular, multi-loculated, cystic tumors in some cases (No. 6,11,14,15,16,20) and hyperenhancement in others (No. 8,9,13,17,18,19). ...
... Of the cases that reported pre-contrast CT findings, five lesions (No. 8,9,11,17,19) were heterogeneous (with both, high and low attenuation), multi-loculated cysts and five (No. 13,14,16,18,20) were hypo-attenuating "cysts" with solid components and peripheral micro-or speckled calcifications. Postcontrast CT showed poorly enhanced or unenhanced, hypo-vascular, multi-loculated, cystic tumors in some cases (No. 6,11,14,15,16,20) and hyperenhancement in others (No. 8,9,13,17,18,19). ...
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Pancreatic hemangioma is a rare type of benign vascular tumor. Low clinical suspicion and inability of current cross sectional imaging techniques to differentiate it from other pancreatic lesions, contribute to the difficulty in making the correct diagnosis. Without a definitive diagnosis, and due to concern for malignancy, in many instances, surgery is performed. We report a case of pancreas cavernous hemangioma in an 18-year-old female. The patient presented with three-month history of epigastric pain. Physical examination and routine blood tests were normal. Abdominal Computed Tomography scan revealed a 5 cm × 6 cm complex non-enhancing cystic mass in the head of pancreas. Magnetic resonance imaging, endoscopic ultrasonography (EUS) and EUS guided fine needle aspiration cytology were non-diagnostic. Because of uncontrolled symptoms, the patient underwent surgical resection. Histopathology and Immunohistochemical staining confirmed the diagnosis of cavernous hemangioma of pancreas.
... Чаще всего это отдельные кли-нические наблюдения [5][6][7][8][9][10][11][12][13][14], иногда с обзором литературных данных [2,15,16]. Лишь в одной работе приведен анализ 15 наблюдений [17]. ...
... Эндо-УЗИ позволяет уточнить диагноз и скорректировать тактику лечения больных. По данным исследователей, применение эндо-УЗИ подтвердило природу образования, позволив применить консервативный и миниинвазивный подход в лечении [17]. ...
... Pancreatic haemangiomas are more common in the paediatric age group, but these do not persist into adulthood (instead undergo involution and regress over several years). 2 A total of 22 case reports describe pancreatic haemangioma in adults; the earliest by Ranstrom in 1939 (Table 1). [3][4][5][6][7][8][9][10] The most common presenting symptom of these reported cases was abdominal pain (accounting for more than half of these cases). This is the first reported case of pancreatic haemangioma presenting with massive bleeding, and requiring an emergency Whipple's procedure. ...
... 6 The use of endoscopic ultrasound was later used in 3 cases, but only one correctly diagnosed pancreas haemangioma. 7 Contrast-enhanced CT was performed in 12 of the cases, with 6 showing poor arterial enhancement, and the other 6 showing hyper-enhancement. Four of the reported cases underwent magnetic resonance imaging (MRI), but only 1 case by Kobayashi 5 showed classical hypo-intensity in T1-weighted images and moderate hyper-intensity signal in T2-weighted images with marked enhancement postgadolinium. ...
Article
Pancreatic haemangiomas are a rare cause of pancreatic lesions in adults. Diagnosis is challenging as they are seldom suspected and difficult to differentiate on imaging. Historically, pancreatic haemangiomas have been managed surgically despite their benign nature, largely due to diagnostic uncertainty. We present the case of a 69-year-old woman who, through combination of radiological, biochemical and endoscopic investigations, was diagnosed with pancreatic haemangioma and managed conservatively, avoiding the morbidity and mortality associated with surgical resection of a benign lesion.
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Adult pancreatic hemangioma is a rare disease. We presented a case of a woman with pancreatic tail mass mimicking a distant metastasis from the kidney. A 68-year-old woman was found with a left kidney mass on medical checkup. Computed tomography scan showed a 4.3 cm-sized mass in the left kidney, suggesting renal cell carcinoma (RCC), and a strongly enhancing tiny nodule in the pancreatic tail. We could not rule the possibility of RCC metastasis, hence, surgical resection of the pancreatic mass simultaneously with radical nephrectomy for RCC was conducted. Gross pathologic examination revealed hemangioma. Immunohistochemistry revealed that the tumor was positive for CD34, CD31 and factor VIII-related antigen. There were no significant postoperative events, and the patient was discharged on postoperative day 7 without any complications. Treatment strategies for pancreatic hemangioma have not been established. To our knowledge, this was the first case report of asymptomatic pancreatic hemangioma. In previous literature, treatment differed on a case-by-case basis, ranging from observation to surgical resection. The most important factor in deciding whether to perform surgery is possibly risk-benefit effectiveness; however, tumor location, patient symptoms, and other factors are also important.
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Rare solid tumors of the pancreas can be misinterpreted as primary pancreatic cancer. The aim of this study was to report our experience in the treatment of patients with rare tumor lesions of the pancreas and to discuss clinical and pathological characteristics in the context of the role of surgery. Data from patients of our prospective data-base with rare benign and malignant tumors of the pancreas, treated in our division from January 2004 to August 2010, were analyzed retrospectively. One-thousand and ninety-eight patients with solid tumors of the pancreas underwent pancreatic surgery. In 19 patients (10 women, 9 men) with a mean age of 57 years (range: 20-74 years) rare pancreatic tumors (metastasis, solid pseudopapillary tumor, teratoma, hemangioma, accessory spleen, lymphoepithelial cyst, hamartoma, sarcoidosis, yolk sac tumor) were the reason for surgical intervention. If rare benign and malignant pancreatic tumors, intrapancreatic metastasis, as well as pancreatic malformations or other abnormalities, present themselves as solid masses of the pancreas, they constitute an important differential diagnosis to primary pancreatic neoplasia, e.g. pancreatic ductal adenocarcinoma. Clinical imaging techniques cannot always rule out malignancy, thus operative exploration often remains the treatment of choice to provide the correct diagnosis and initiate adequate surgical therapy.
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We report an adult pancreatic hemangioma diagnosed on pathological specimen review following pylorus preserving pancreaticoduodenectomy for a symptomatic cystic mass in the head of the pancreas. Eight cases of adult pancreatic hemangioma have been reported in literature since 1939. Presenting symptoms, radiographic diagnosis, pathologic characteristics, and treatment of adult pancreatic hemagiomas are discussed following review of all published cases. Copyright (C) 2009 Gerhard S. Mundinger et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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The pancreas is an unusual site for a hemangioma in an infant. A child with obstructive jaundice caused by a pancreatic hemangioma is presented and management strategies for this benign tumor are discussed. A 5-month-old girl presented with a 2-week history of jaundice, pale stools and dark urine. Liver function tests confirmed obstructive jaundice. An abdominal ultrasound scan and magnetic resonance imaging showed an enhancing mass in the head of the pancreas. At laparotomy, a wedge biopsy of the pancreatic tumor was taken and a tube cholecystostomy inserted. Histological examination of the specimen revealed a pancreatic hemangioma with sclerotic features. The high volume of bile loss from the cholecystostomy proved problematic and biliary diversion with a Roux-en-y hepaticojejunostomy was therefore performed. The tumor subsequently regressed spontaneously and was no longer visible on follow-up imaging two years later. The child has since thrived. Pancreatic hemangiomas are rare and may cause diagnostic confusion. Pancreatic resection should be avoided since the natural history of these benign tumors is that of spontaneous involution. Various strategies can be used to manage any associated obstructive jaundice.
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