Case Report

A 70-years-old man presented with weight loss. He reported heavy smoking and consumption of 2 units of alcohol per day.

A thoracic and abdominal computed tomography was performed and revealed cephalic pancreatic enlargement with multiple calcifications scattered throughout the pancreas, a hypodense mass in the uncinated process and irregularly dilated main pancreatic duct.

Endoscopic ultrasound showed multiple diffuse infracentimetric pancreatic cysts, most of which with small foci of mural calcification, communicating with the main pancreatic duct, two larger cysts with 20mm and 19mm in the head and uncinated process, respectively, with calcifiedmural nodules, and main pancreatic duct dilatation in the cephalic pancreas (max 4.6mm) (Figure 1)

Figure 1 – EUS showed multiple diffuse infracentimetric pancreatic cysts communicating with the main pancreatic duct, with small foci of mural calcification.

Quiz

What is the most likely diagnosis?

 

Discussion

Endoscopic ultrasound-guided fine-needle-aspiration using a 22Gneedle of the largest cyst was performed with drainage of viscous fluid positive for mucin stain. Cytology was negative for malignancy and cyst fluid analysis revealed elevated amylase and CEA, consistent with multifocal branch-duct intraductal papillary mucinous neoplasms (IPMN) with psammomatouscalcifications.

Although relatively rare, cystic lesions of the pancreas are considered to be an increasingly important category with a spectrum of histology and malignant potential1.

IPMN are detected with increasing frequency as more patients are exposed to radiologic imaging modalities2. Calcifications within IPMN have been reported, with a frequency ranging from 10% to 25%, however its significance is still unknown2. They are usually focal and peripheral3.Punctate calcification have been seen in approximately 90% of cases, whereas coarse and eggshell calcification have been less commonly described2,3. The presence of punctate calcification has not been associated with malignancy, however coarse calcifications have been associated with malignancy in some cohorts2,3. The most likely explanations for the calcification in IPMN are presence of thick mucin, which has a propensity to build up calcium salt deposits, and coexisting chronic calcifying pancreatitis2.

 

References

  1. Li T, Chen ZQ, Meng ZX et al. Calcified cystic lesion of the pancreas. J Gastrointest Surg. 2016;20:1272-4
  2. Perez-Johnston R, Narin O, Mino-Kenudson et al. Frequency and significance of calcification in IPMN. Pancreatology. 2013; 13:43-47
  3. Verde F, Fishman EK. Calcified pancreatic and peripancreatic neoplasms: spectrum of pathologied. Abdom Radiol. 2017; 42:2686-2697

Authors

Catarina Félix1, Susana Marques1, Miguel Bispo2, Cristina Chagas1

  1. Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon
  2. Gastroenterology Departement, Fundação Champalimaud, Lisbon