|Year : 2019 | Volume
| Issue : 1 | Page : 21-23
Isolated hydatid cyst of pancreatic tail masquerading as serous cystadenoma
Shipra Verma1, Gurpreet Walia1, Shrirang Vasant Kulkarni2, Deepti Mutreja1
1 Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Surgery, Command Hospital, Pune, Maharashtra, India
|Date of Submission||07-Nov-2019|
|Date of Acceptance||19-Feb-2020|
|Date of Web Publication||16-Apr-2020|
Dr. Deepti Mutreja
Department Pathology, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Hydatid cyst is a common health-related entity in the developing world but is rarely seen as an isolated lesion in pancreas. It is mostly seen as a part of multisystem infection. It masquerades as cystic neoplasms clinically and radiologically, making its diagnosis a challenge. A high index of suspicion is required for timely diagnosis of such cases. We present one such rare case where a 50-year-old female patient was diagnosed as a case of serous cystadenoma on radiology. The patient underwent distal pancreatectomy with splenectomy for the same and on histopathology the lesion was diagnosed to be hydatid cyst of pancreas.
Keywords: Cystadenoma, hydatid cyst, pancreatic cyst, pancreatic pseudocyst
|How to cite this article:|
Verma S, Walia G, Kulkarni SV, Mutreja D. Isolated hydatid cyst of pancreatic tail masquerading as serous cystadenoma. Arch Int Surg 2019;9:21-3
| Introduction|| |
Hydatid cyst is a common health problem in the developing world and endemic in nations like Argentina, Central Asia, China, East Africa, Peru, and India., The most common organs affected include liver (65%–70%) and lung (25%), but other sites like spleen, brain, bones, retroperitoneal space, and muscles are also rarely involved.,, Pancreas may be involved as a part of multisystem infection. Isolated involvement of pancreas is seldom reported in the literature even in endemic areas, and forms only 0.2%–2% of cases., We report a rare case of isolated hydatid cyst of pancreatic tail which presented with pain abdomen and was misdiagnosed as serous cystadenoma on imaging.
| Case Report|| |
A 50-years-old woman, with no known co-morbidities, was admitted with recurrent pain abdomen for 03 months. The pain was localized in the periumbilical region, intermittent, mild-to-moderate in intensity and aggravated post meals. There was associated anorexia and malaise. There was no history of fever, jaundice, or weight loss.
On examination, the patient was averagely built and nourished. General physical examination was unremarkable. Abdomen was soft. Epigastric tenderness was present. There was no free fluid or organomegaly. Routine hematologic and biochemical investigations were unremarkable.
An ultrasound of abdomen [Figure 1]a showed bulky pancreas with well-defined hypoechoic lesion measuring 62 × 61 mm without significant vascularity near tail of pancreas. Peripancreatic edema was noted.
|Figure 1: (a) Abdominal Ultrasonography: Cystic lesion measuring 62 × 61 mm near tail of pancreas (white arrows). (b) CT scan (Axial section): Well-circumscribed cystic lesion measuring 5.2 × 7.0 × 7.1 cm involving body and tail of the pancreas showing multiple peripherally distributed small cysts (red arrow). Mass effect of the lesion onto splenic vein and artery and collateral reformation seen|
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Computed tomography (CT) scan [Figure 1]b revealed a well-circumscribed lesion measuring 5.2 × 7.0 × 7.1 cm, involving body and tail of the pancreas showing multiple peripherally distributed small cysts. The mass effect of the lesion onto splenic vein and artery and collateral formation was noted. An imaging diagnosis of serous cystadenoma of the pancreas was offered. Tumor marker studies were undertaken which were normal (CEA-2.4 ng/ml (<5.0 ng/ml), CA19.9: 25.87 U/ml (0–37.0 U/ml.
The patient underwent distal pancreatectomy with splenectomy. On examination, the specimen [Figure 2]a and [Figure 2]b of distal pancreatectomy measured 15 × 8.5 × 3 cm. Spleen weighed 200 g and was unremarkable on external and cut surface. The external surface of pancreatic tail was enlarged and globular. On cutting open, a multilocular cyst with thick brownish hard outer cyst wall and numerous satellite inner whitish thin-walled cysts were seen. Cut surface exuded clear serous fluid and whitish material.
|Figure 2: (a) External surface of spleen and distal pancreatectomy (white arrow). (b) Cut surface shows multiloculated cyst with outer thick wall (red arrow) and whitish thin translucent inner walls containing whitish flaky material and serous fluid (black arrows)|
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Microscopic sections [Figure 3]a and [Figure 3]b show a cyst wall lined by thick fibrous outermost layer (pericyst) and middle lamellated, hyaline and acellular layer (ectocyst) along with endocyst (germinal layer) which consisted of numerous daughter cysts and brood capsules with calcified scolices and hooklets. Contents reveal lamellated keratinous material. There was no evidence of malignancy.
|Figure 3: (a) (H and E, 100×): Lamellated, hyaline and acellular layer (ectocyst) (white arrow) along with endocyst (germinal layer) (black arrow). (b) (H and E, 200×) Endocyst (germinal layer) which consists of numerous daughter cysts and brood capsules with calcified scolices (yellow arrow) and hooklets (red arrow)|
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| Discussion|| |
Hydatid disease is a cyclozoonotic infection caused by Echinococcus granulosus. Humans are the end host for this parasite. Isolated pancreatic hydatid cyst is rare with few reported cases in the literature.,,,,, The distribution of hydatid cyst in pancreas is most commonly in the head, followed by body and tail, which comprises less than 20% of all pancreatic hydatid cysts. The most common route of spread is hematogenous dissemination from the intestinal mucosa. The other probable routes of spread to the pancreas are passage through the biliary system and lymphatic spread. Clinically, patients may present with abdominal pain and features of obstructive jaundice when affecting the head of pancreas. It is mostly asymptomatic when the cyst is present in the body and tail of pancreas., Our patient presented with recurrent episodes of abdominal pain and epigastric tenderness mimicking an acute abdomen.
Radiological diagnosis of hydatid cyst of pancreas using ultrasound scan of abdomen may be difficult as it may masquerade pancreatic pseudocyst or intrapancreatic cystic neoplasms. The characteristic CT findings of hydatid cyst include: a cystic lesion with undulating floating membranes (water-lily sign), presence of daughter cysts or hydatid sand (debris), and septations and curvilinear calcifications in the cyst wall., In pancreatic hydatid cysts, these classic findings are sometimes masked due to retroperitoneal location and presence of bowel gas, thus decreasing the sensitivity of USG abdomen. Radiology alone, in the absence of clinical inputs and serological investigations that demonstrate echinococcal antigen, may be inconclusive and surgical exploration may be required to make a definitive diagnosis. The mainstay of treatment remains surgical resection. Alternatively, in this case, a conservative surgery with splenic preservation could have been done.
Hydatid cyst should always be kept in differentials while dealing with cystic lesion of pancreas, especially in endemic areas. Strong imaging suspicion together with serological tests against echinococcal antigen and high index of suspicion can help in preoperative diagnosis, guiding appropriate treatment and avoiding complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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