Obstructive jaundice secondary to pancreatic adenocarcinoma in a seven-year-old male

Management of children with pancreatic head mass

The management of children with a mass in the head of the pancreas is not well defined. The medical records of 3 children with obstructive jaundice because of a mass in the head of the pancreas over a 4-year period were reviewed retrospectively. Abdominal ultrasonography and computed tomography showed intrahepatic and extrahepatic ductal dilatation and a pancreatic mass. Intraoperative frozen section revealed no evidence of malignancy. These patients were separately managed by pylorus-preserving pancreaticoduodenectomy, cholecystectomy and Roux-en-Y choledochojejunostomy, common duct exploration, and T-tube drainage. The final pathology of the pancreatic head mass in all cases demonstrated chronic pancreatitis. Follow-up at an average of 7 months postoperatively showed no recurrence of obstructive jaundice. Unlike adults with a mass in the head of the pancreas, it is recommended that children with similar presentation should undergo biopsy and biliary diversion rather than resection as the primary therapy. Adults presenting with similar radiologic and clinical features would be treated by a pancreaticoduodenectomy in the absence of histologic evidence of malignancy. This series would suggest histologic conformation should be obtained before radical surgery in children.

Molecular characterisation of pancreatic ductal adenocarcinoma in patients under 40

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) rarely affects people under 40.

OBJECTIVES

To determine whether the clinical, pathomorphological and genetic features of PDAC occurring in young patients (<or=40 years) differ from those in elderly patients.

METHODS

Clinical and pathomorphological data were obtained from seven patients presenting with PDAC, with age ranging from 35 to 40 years of age (mean 38 years). All tumours were characterised by using immunohistochemistry and molecular genetics.

RESULTS

All seven patients were women and lacked an association to cancer-predisposing genetic syndromes. Four patients were smokers and one had non-hereditary chronic pancreatitis. Pathomorphologically, tumours in three patients displayed moderate differentiation and four showed poor differentiation including one adenosquamous carcinoma. All tumours showed overexpression of transforming growth factor beta1 and loss or significant reduction of Smad4. Accumulation of p53 and overexpression of epidermal growth factor receptor (EGFR) were seen in five and four patients, respectively. No expression of p16, oestrogen hormone receptor or progesterone receptor was found. Mismatch repair gene products (MutL homologue 1 (MLH1), MSH2 and MSH6) were expressed in all tumours. Mutational analyses showed K-ras mutations in only three of the seven tumours.

CONCLUSION

A large clinical, pathomorphological and genetic overlap of PDAC in young patients aged under 40 is seen with that in elderly patients. The existence of yet undefined initiating events of pancreatic carcinogenesis is suggested by the low rate of K-ras mutations, in at least a subgroup of young patients.

Rare ductal adenocarcinoma of the pancreas in patients younger than age 40 years

BACKGROUND

Pancreatic ductal adenocarcinomas (PDACs) are extremely rare before age 40 years. The objective of the current study was to determine whether the features of PDACs in patients age < 40 years differ from those in older patients. The authors reviewed the literature and their own files.

METHODS

The cases reported in the literature were evaluated to determine their precise diagnoses and characteristic features. In a series of 439 PDACs from the authors' files, tumors in patients age < 40 years were identified, and their clinicopathologic features and certain genetic features were compared with those in a selected group of patients age > 40 years.

RESULTS

Of 71 pancreatic carcinomas reported in patients age < 40 years, only 20 fully qualified as PDACs. The remaining tumors represented malignancies other than PDACs, such as pancreatoblastoma, solid-pseudopapillary neoplasms, acinar cell carcinomas, and endocrine tumors. PDACs in patients age < 20 years were the absolute exception and commonly were associated with risk factors such as Peutz-Jeghers syndrome, hereditary pancreatic cancer syndrome, and preceding radiotherapy. In the authors' series of patients, there were 6 PDACs and 4 PDAC variants in patients age < 40 years (0.2%), all in male patients. These tumors compared well with the PDACs in patients age > 40 years in their pathologic and molecular findings. Three patients were age < or = 20 years, and 2 of those patients had a mucinous component with MUC2 positivity.

CONCLUSIONS

The incidence of PDACs in patients age < 40 years was approximately 0.3%, and the incidence in patients age < 20 years was 0.1%. Their clinicopathologic findings were comparable to those in patients age > 40 years, but they seemed to include more variants, particularly mucinous carcinomas. In addition, PDACs in younger patients frequently appeared to be associated with genetic factors.

Obstructive jaundice secondary to lymphoma in childhood

In children, biliary obstruction secondary to lymphoma is rare. Previous reports in adults and children suggest that these lymphomas are associated with a poor prognosis. The authors reviewed the medical records and imaging studies of 4 children treated for pancreaticobiliary lymphoma at our children's hospital over the past 10 years. All 4 presented with jaundice. Abdominal ultrasound scan and computed tomography (CT) scans were helpful in defining the anatomy of the obstruction. In the cases of involvement of the porta hepatis, the diagnosis was made by biopsy. In one child a mass was in the head of the pancreas, and evaluation of frozen section biopsy results were not diagnostic for lymphoma, and a major resection was performed. All the lymphomas were of nonHodgkin's B-cell type and one was a Burkitt's lymphoma. All responded promptly to chemotherapy. One child had a testicular relapse and currently is receiving additional therapy. Pancreaticobiliary lymphomas are an unusual cause of obstructive jaundice in children. Biopsy alone without resection or biliary drainage is recommended surgical therapy. Long-term survival rate in children with this disorder appears to be more promising than previously reported. J Pediatr Surg 36:1792-1795.

A 20-year review of pediatric pancreatic tumors

Pancreatic tumors are rare surgical problems in infants and children. A 20-year audit (1971 to 1991) of this institution showed six patients ranging in age from 3 weeks to 16 years who were operated on for pancreatic neoplasms. Five of these tumors were malignant, bringing the reported experience to 71 cases. This series of malignancies included three solid cystic tumors, one insulin-secreting tumor, and one pancreatoblastoma. The clinical presentations varied: three had abdominal pain, one developed hypoglycemia, and one had an abdominal mass with jaundice. In five of the six patients pancreatic pathology was suspected preoperatively. All were treated primarily with pancreatic resection including one pancreatoduodenectomy. No radiotherapy or chemotherapy was used. The perioperative mortality was 0% with a morbidity of 50%. The long-term results are encouraging, with all patients alive after a mean follow-up of 7.8 years. These data suggest that aggressive surgical therapy is warranted in the management of pediatric pancreatic tumors.

Adenocarcinoma of the pancreas in a neonate managed by pancreatoduodenectomy

A 3-week-old infant presenting with jaundice and an abdominal mass was found to have juvenile adenocarcinoma of the pancreas (pancreatoblastoma). A pancreatoduodenectomy was performed, and the child is alive, well, and free of disease at age 4 years. The operative management and surgical technique are discussed.