Cavernous hemangioma of the pancreas: report of a case

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine contrast-enhanced ultrasound guidelines: Multiparametric imaging and EUS-guided sampling in rare pancreatic tumors. Benign mesenchymal pancreatic tumors

The focus of the review is on primary benign mesenchymal pancreatic tumors and their imaging appearance. These tumors are extremely rare. Usually, they are not diagnosed until postoperative histology is available, and so even benign tumors have undergone extensive pancreatic resection. The very limited data on abdominal and EUS findings including contrast-enhanced techniques of these pancreatic lesions are summarized here. Case reports will be presented for some of these rare tumors with application of modern ultrasound and endosonographic techniques.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine contrast-enhanced ultrasonography guidelines: multiparametric imaging and EUS-guided sampling in rare pancreatic tumors. Mesenchymal pancreatic tumors of intermediate biological behaviour

The focus of the review is on mesenchymal pancreatic tumors with intermediate biological behavior and their imaging appearance. Similar to benign and malignant mesenchymal pancreatic tumors, these tumors are extremely rare. The diagnosis is often confirmed only by postoperative histology. The very limited data on abdominal ultrasound and EUS findings including contrast-enhanced techniques of these pancreatic lesions are summarized here.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine guidelines: Rare pancreatic tumors, ultrasound and contrast-enhanced ultrasound features-Malignant mesenchymal tumors

Rare malignant mesenchymal pancreatic tumors are systematized and reported in this review. The focus is on the appearance on imaging. The present overview summarizes the data and shows that not every pancreatic tumor corresponds to the most common entities of ductal adenocarcinoma or neuroendocrine tumor.

Pancreatic cavernous hemangioma complicated with chronic intracapsular spontaneous hemorrhage: A case report and review of literature

BACKGROUND

Pancreatic cavernous hemangioma (pCH) is a rare type of benign vascular tumor. Making the right diagnosis is challenging due to low clinical suspicion and the lack of existing cross-sectional imaging tools to distinguish it from other pancreatic lesions.

CASE SUMMARY

We describe a male patient, age 18, who presented with a pCH. Computed tomography, magnetic resonance imaging, and ultrasound showed cystic space in the tail of the pancreas. A dark spot sign on the T2 weighted image sequence was observed. Clinically, a mucinous cystic neoplasm with hemorrhage was suspected preoperatively by combining imaging, and the operative indication was clear. The patient underwent a distal pancreatic tumor resection under laparoscopic control. Immunohistochemical staining for CD31 and CD34 was positive; D2-40 was positive in interstitial lymphatic vessels and negative in vascular epithelial cells; and calcium-binding protein was negative. The results support the diagnosis of pCH combined with chronic intracapsular spontaneous hemorrhage. No complications or recurrences were observed during the follow-up period.

CONCLUSION

Chronic spontaneous hemorrhage may occur in pCH, which may greatly influence the accuracy of diagnosis using imaging modalities. Surgical resection for uncertain pCH seems reasonable with a good outcome.

Retroperitoneal cavernous hemangioma misdiagnosed as lymphatic cyst: A case report and review of the literature

BACKGROUND

Primary abdominal and retroperitoneal cavernous hemangioma is a vascular tumor and rarely seen in the clinic. Due to the lack of specific imaging features, retroperitoneal cavernous hemangioma cannot be diagnosed accurately. Some symptoms may develop with the enlargement of lesion volume or the occurrence of complications such as rupture or oppression. We report here a special case who was admitted with chronic abdominal pain. Admission examination suggested a retroperitoneal lymphatic duct cyst. Laparoscopic resection of the retroperitoneal mass was performed, and histological examination confirmed retroperitoneal cavernous hemangioma.

CASE SUMMARY

The patient was a 43-year-old Tibetan woman with intermittent left lower abdominal pain and discomfort 3 years ago. Ultrasonography revealed a cystic mass in the retroperitoneum with clear boundaries, internal septa, and no blood flow signal. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an irregular space-occupying mass in the retroperitoneum, and retroperitoneal lymphatic cyst was considered. Plain CT scanning showed multiple cyst-like hypo-intense shadows in the retroperitoneum, partially fused into a mass, and no obvious enhancement was found on enhanced scanning. MRI showed multiple irregular clump-like long T1 and long T2 signal shadows above the pancreas, within which linear short T2 signal shadows were seen. Diffusion-weighted imaging sequence showed hypo-signal shadows, without obvious enhancement on enhanced scanning. Ultrasound, CT, and MRI all suggested the possibility of retroperitoneal lymphatic cyst. However, the patient was finally diagnosed with retroperitoneal cavernous hemangioma by pathological examination.

CONCLUSION

Retroperitoneal cavernous hemangioma is a benign lesion, and it is difficult to make a diagnosis preoperatively. Surgical resection may be the only treatment, which not only allows histopathological confirmation as a diagnostic purpose and excludes any risk of malignancy, but also avoids invasion of adjacent tissues, oppression, and other complications as a therapeutic goal.

Conservative management of adult pancreatic haemangioma: case study and literature review

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.

Rare adult pancreatic hemangioma: review of the literature with a case report

Adult pancreatic hemangioma is an especially rare benign tumor that is hard to diagnose through imaging examinations, meanwhile its histopathological and immunohistochemical studies have rarely been reported. At this time, only 29 cases in 27 publications have been reported. We report a new case as well as review these literatures. A 71-year-old woman came to our hospital with slight pain on left upper abdomen for three days. But the results obtained from the physical or laboratory examination were all negative so that her symptoms could not be explained clearly. The imaging examinations including ultrasonography and computed tomography both showed a mixed mass in the neck of the pancreas. The preoperative diagnosis of cystadenoma or adenocarcinoma was made, with high suspicious of malignancy. The patient underwent a central pancreatectomy with pancreatojejunostomy, but the pathologic diagnosis was pancreatic hemangioma. The immunohistochemical examination found the positive benign vascular markers (CD31, CD34) and negative lymphocyte markers (D2-40). Moreover, Ki-67 negativity also revealed its benign nature. After 36 months of follow-up, the patient has no complaints for abdominal pain. In conclusion, adult pancreatic hemangioma is extremely rare without any specific clinical manifestations. It is usually diagnosed postoperatively by histological examination and immunohistochemical studies. Imaging examinations, including computed tomography and magnetic resonance imaging, can't give definite conclusion. Endoscopic-ultrasound guided fine needle aspiration is conditionally worth doing, which can give some hints and exclude the malignancy of the lesion. If malignancy can be safely ruled out, the surgical decision must be made according to risk-benefit analysist. Maybe close observation and regular follow-up are more beneficial options.

Adult pancreatic hemangioma: a rare case report and literature review

Background

Adult pancreatic hemangioma is an extremely rare type of benign vascular tumor. To date, about 20 cases have been reported in the English literature. Adult patients with pancreatic hemangiomas usually have no specific symptoms, particularly in early stages. Therefore, it is difficult to detect and diagnose these lesions, which usually are identified during cross sectional imaging for an apparently unrelated causes or when biliary obstruction occurs because of compression by a tumor.

Case presentation

This study presents the case of a 52-year-old female with a chief complaint of epigastric pain. Contrast-enhanced computed tomography revealed a well-defined mass with mildly inhomogeneous enhancement in the body of the pancreas. Endoscopic ultrasonography showed calcifications in the lesion, and a few small vessels were detected by Doppler imaging. The patient received a central pancreatectomy, and pathological examination confirmed the diagnosis of pancreatic hemangioma.

Conclusion

In this report, we reviewed the clinical manifestations, radiologic features, preoperative diagnosis, pathologic characteristics, and surgical treatment of adult pancreatic hemangioma.

Adult pancreatic cavernous hemangioma: case presentation of a benign tumor with a complex composition

Background

Pancreatic cavernous hemangioma is an extremely rare benign tumor that is difficult to diagnose on an imaging examination, and its histopathological examination has rarely been reported.

Case presentation

Herein, we present the case of a 63-year-old man who was admitted to the hospital due to left upper abdominal pain and defecation unformed for more than 2 years. None of the positive results obtained from the physical examination could explain his symptoms. The imaging examination indicated a multilocular cyst with septa in the head of the pancreas. The patient underwent a pancreaticoduodenectomy, and the pathologic diagnosis was pancreatic cavernous hemangioma. The histopathological examination showed that the lesion was positive for benign vascular markers, such as CD31, CD34 and F8, and negative for lymphocyte markers, such as D2–40. Moreover, it was also positive for ERG and cytokeratin markers, CAM5.2 and AE1/AE3, indicating the complexity of its components, and Ki-67 negativity revealed its benign nature.

Conclusions

Pancreatic cavernous hemangioma has a complex composition that may be reflected not only in the imaging examination but also in the immunohistochemical detection, and it may achieve a good outcome by surgical excision.

Rare case of adult pancreatic haemangioma and literature review

Pancreatic haemangiomas are benign vascular tumours very rare in adults. Twenty-two cases are described in the literature. The symptoms are non-specific, and therefore rarely clinically suspected, and the vast majority are incidental findings in imaging tests such as ultrasound, CT, angiography or MRI. They appear on CT as a cystic lesion with contrast enhancement in the arterial phase. We present the case of a 36-year-old male patient with no history of disease, referred with lumbar pain and suspected renal calculus after tomography showing hypervascular enhancement in the pancreatic body and infiltrative lesion (possible neuroendocrine neoplasia) on MRI and biliopancreatic echoendoscopy. He was submitted to laparotomy with subtotal pancreatectomy and splenectomy and satisfactory evolution.

Primary mesenchymal tumors of the pancreas in a single center over 15 years

In total, 95% of primary tumors in the pancreas are epithelial tumors; primary mesenchymal tumors at this site are extremely rare. At present, only one comprehensive study about these rare tumors has been performed. Another retrospective analysis of these rare tumors is performed in the present study, which, to the best of our knowledge, is the first to be performed in China. In the present study, 10 patients that underwent resection for primary mesenchymal tumors of the pancreas were identified in a 15-year period at the Chinese Academy of Medical Sciences and Peking Union Medical College, which accounted for 0.51% of the total surgically resected primary tumors of the pancreas at this hospital. Among the 10 patients, 7 patients (70%) were diagnosed with benign/borderline tumors, and the remaining 3 patients (30%) were diagnosed with malignant tumors. It was a unique finding of the present study that the preoperative diagnosis was frequently a misdiagnosis, in terms of the specific pathological diagnosis. Therefore, although primary mesenchymal tumors of the pancreas are extremely rare, they should be considered in order to make the correct preoperative diagnosis. Contrarily to a previous study, in the present study, the most common benign tumor was not desmoid tumor, but solitary fibrous tumors; the most frequent primary sarcoma was not undifferentiated/unclassified sarcoma either. In conclusion, the present study aids the understanding of these rare tumors; however, primary mesenchymal tumors of the pancreas require additional exploration in the future.

Incidental detection of pancreatic hemangioma mimicking a metastatic tumor of renal cell carcinoma

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.

Cavernous hemangioma of adult pancreas: A case report and literature review

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.

Rare case of adult pancreatic hemangioma and review of the literature

Pancreatic hemangiomas are a rare type of cystic tumor, with very few cases reported in the literature. Herein, we present the case of a 28-year-old woman who was admitted to our hospital for abdominal pain. A physical examination failed to reveal any abnormalities that could explain her symptoms. A contrast-enhanced computed tomography showed a multilocular cyst with moderately enhanced septa and fluid-fluid levels in the body and tail of the pancreas. A serous cystadenoma or pseudocyst of the pancreas was initially suspected, and the patient underwent a subtotal pancreatectomy and splenectomy. The pathologic diagnosis was a pancreatic hemangioma. This is the second case of pancreatic hemangioma with fluid-fluid levels reported in the literature. Upon imaging, the presentation of this tumor can resemble serous or mucinous cystadenomas, pseudocysts of the pancreas, and side-branch type intraductal papillary mucinous neoplasms. This report reviews the clinical symptoms, radiologic features, pathologic characteristics, differential diagnoses, and treatment of this rare lesion type.

Primary mesenchymal tumors of the pancreas: single-center experience over 16 years

OBJECTIVE

Primary mesenchymal tumors of the pancreas are extremely rare and no comprehensive study of this class of tumors has been previously performed.

METHODS

Twenty cases of the primary mesenchymal tumors of the pancreas were selected and compared clinicopathologic variables with consecutively resected 500 pancreatic ductal adenocarcinomas.

RESULTS

Finally, 20 (0.3%) cases were confirmed as primary mesenchymal tumors. The 14 (70%) cases of benign/borderline tumors included 4 cases of fibromatoses, 2 cases of cavernous hemangiomas, 2 cases of schwannomas, 2 cases of solid and cystic hamartomas, 2 cases of solitary fibrous tumors, 1 case of inflammatory myofibroblastic tumor, and 1 case of angiomyolipoma. The 6 (30%) cases of sarcomas comprised 3 cases of undifferentiated/unclassified sarcomas, 1 case of leiomyosarcoma, 1 case of Ewing sarcoma/primitive neuroectodermal tumor, and 1 case of atypical lipomatous tumor/well-differentiated liposarcoma. When compared with the 500 ductal adenocarcinomas, the 3 surgically resected sarcomas were larger (mean, 5.8 cm vs 3.6 cm; P = 0.02); however, no difference in median survival time was observed between patients with sarcoma (23 months) and patients with ductal adenocarcinoma (16 months).

CONCLUSIONS

First, primary mesenchymal tumors of the pancreas are extremely rare. Second, several primary mesenchymal tumor types can be observed in the pancreas. Understanding these rare disease entities will help ensure their correct diagnosis.

Endoscopic ultrasonography allowing expectant management of pancreatic haemangioma

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.

Adult pancreatic hemangioma: A case report

Vascular neoplasms of the pancreas are extremely rare and usually manifest as symptomatic, cystic lesions. This study presents a case that includes the clinicopathologic information used to discriminate pancreatic hemangioma from other types of cystic lesion of the pancreas. A 40-year-old female visited hospital with a chief complaint of abdominal pain. The serum CEA and CA19-9 levels of the patient were within the normal limits. An abdominal computed tomography scan and magnetic resonance imaging showed a 100-mm mass lesion in the body and tail of the pancreas, and the tumor extended toward the retroperitoneum and surrounded the splenic vein. The lesion was subsequently resected. Macroscopically, it was a multiloculated cyst with intracystic hemorrhage. Microscopically, the lesion was composed of numerous, heterogeneous cysts lined by a flattened single layer of cells without significant atypia. Notably, numerous neoplastic vessels extended into the interlobular septa of the pancreas and surrounded the main pancreatic duct. Immunohistochemical analysis showed that the lining cells expressed CD31 and CD34. The lesion was diagnosed as adult pancreatic hemangioma. Surgical treatment may be required when a direct contact between the lesion and the pancreatic tissue is demonstrated using imaging.

Unusual features in an adult pancreatic hemangioma: CT and MRI demonstration

Hemangiomas in the pancreas are very rare and only a few cases in adulthood have been reported in the literature. We describe a case of pancreatic hemangiomas in an adult with unique imaging findings. A 23-year-old woman visited the hospital for an incidentally detected pancreatic mass. CT and MRI revealed a multilocular cyst with fluid-fluid levels and no obvious enhancement. The patient underwent surgery and the mass was confirmed as a pancreatic hemangioma. The radiological features and differential diagnosis of this rare lesion are discussed.

Adult primary retroperitoneal cavernous hemangioma: a case report

Primary retroperitoneal cavernous hemangioma (PRCH) in an adult is extremely rare. We report on the diagnosis and treatment of a patient with PRCH with subtle clinical features and atypical findings on imaging scans. A 38-year-old man was admitted to hospital with a 5-day history of epigastralgia after alcohol drinking. Using various imaging methods, we found a giant cyst-like retroperitoneal mass compressing the surrounding organs. Surgical resection of the tumor was performed, and the mass was found to be a cavernous hemangioma measuring 90 × 80 × 60 mm, with a thick fibrotic wall and extensive intracystic hemorrhage. Physicians should be aware that PRCH may mimic a cystic neoplasm, and that a large tumor size probably indicates intracystic hemorrhage. Surgical resection is a curative approach for PRCH.

Adult pancreatic hemangioma: case report and literature review

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.

Complex pancreatic vascular anomalies in children

BACKGROUND

Vascular anomalies are vascular tumors and congenital malformations that rarely involve the pancreas. Diagnosis and management of these lesions is complex.

METHODS

An institutional review board-approved retrospective database and record review from 1994 through 2004 at a quaternary referral center for vascular anomalies was conducted.

RESULTS

Of 5051 patients with a vascular anomaly, 6 had a lesion involving the pancreas. All patients were younger than 3 years. There were three tumors (two infantile hemangiomas and one Kaposiform hemangioendothelioma) and three malformations (two lymphatic and one venous). The referring diagnoses were correct for 4 patients. All anomalies were diagnosed with a combination of cross-sectional imaging and angiography. Five patients received medical therapy including two malformation patients who were initially treated with antiangiogenic drugs. Two patients with lymphatic malformations underwent operative intervention. One infantile hemangioma was treated with percutaneous biliary drainage for obstructive jaundice.

CONCLUSION

Complex pancreatic vascular anomalies are rare. Vascular tumors are generally amenable to treatment with antiangiogenic medications. Operative resection is reserved for refractory cases or complications. Symptomatic vascular malformations are treated exclusively by surgery. Evaluation and management of these lesions is complex and may benefit from coordinated interdisciplinary care.