20210729湘雅二医院课件荟萃【1787】
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● Clinical Presentation
● A 63-year-old man presents with weight loss and abdominal pain.
● 临床表现：
● 男，63岁，腹痛伴体重减轻。
● 1A - Annotated Caption
● (A) Arterial-phase contrast-enhanced computed tomography (CT) shows marked dilatation of the common bile duct (arrow) and gas in an intrahepatic duct, likely from endoscopic retrograde cholangiopancreatography (arrowhead).
● 1A-影像表现：
● (A) 增强CT示：肝内胆管（三角箭头）和气体的明显扩张，可能来自内镜逆行胰胆管造影术（箭头）。
● 2B - Annotated Caption
● (B) More caudal image shows the gastric antrum (arrowhead) and marked dilatation of the pancreatic duct (arrow). There is atrophy of the pancreatic body and tail.
● 2B- 影像表现：
● (B) 可见胃窦（三角箭头）和明显的胰管扩张（箭头）。胰腺体部和尾部萎缩。
● 3C - Annotated Caption
● (C) More caudal image shows a hypoattenuating mass (oval) with no clear fat plane separating this mass from the adjacent duodenum (large arrowhead) and inferior vena cava (small arrowhead)
● 3C- 影像表现：
● (C) 低密度肿块（椭圆形）与相邻的十二指肠（大箭头）和下腔静脉（小箭头）间无脂肪成分。
● Further Work-up
● No Further Work-up
● 进一步处理后：
● 无进一步处理
● Differential Diagnosis
● Pancreatic adenocarcinoma: This is the most likely diagnosis, given the patient’s age and presentation, the hypoattenuating mass in the pancreatic head, the obstruction of both the common bile duct and the pancreatic duct, and the obliteration of fat planes between the mass and the adjacent duodenum and inferior vena cava.
● Metastasis: This is a possibility but statistically less likely.
● Focal pancreatitis: This is a possibility, but the clinical presentation suggests neoplasm.
● 鉴别诊断
● 胰腺癌：可能性大，依据：病人的年龄和表现，胰头的低密度肿块，胆管和胰管均有梗阻，肿块与相邻的十二指肠和下腔静脉间无明显脂肪成分。
● 转移：可能性较低。
● 局灶性胰腺炎：可能，但临床表现提示肿瘤。
● Essential Facts
● This case illustrates the often subtle appearance of pancreatic adenocarcinoma due to mild to moderate enhancement compared with adjacent structures.
● In many cases, early pancreatic carcinoma or ampullary carcinoma is discovered based solely on the “double-duct” sign (both the pancreatic duct and the common bile duct).
● Pancreatic adenocarcinoma is a malignant tumor usually originating from duct cells and occurring after 55 years of age.
● Predisposing conditions include smoking, a history of alcohol-related or hereditary pancreatitis, and diabetes.
● Clinical presentation may include the new onset of diabetes, jaundice, pain radiating to the back, and nonspecific constitutional symptoms of nausea and weight loss.
● 知识点：
● 本病例示：胰腺癌与邻近结构相比，增强扫描成轻度至中度强化。
● 在许多情况下，早期胰腺癌或壶腹癌常常基于“双管征”而发现（包括胰管和胆总管）。
● 胰腺癌是一种恶性肿瘤，通常起源于导管细胞，55岁以后发生率高。
● 诱发条件包括吸烟，酒精或遗传性胰腺炎、糖尿病史。
● 临床表现包括：新发的糖尿病，黄疸，背部疼痛，以及恶心和体重减轻等非特异性症状。
● Other CT findings suggesting adenocarcinoma are location in the pancreatic head (60%), centrally hypoattenuating necrosis, effacement of peripancreatic fat planes, invasion of adjacent organs (usually duodenum and stomach), invasion or encasement of adjacent vessels, regional adenopathy, and distant metastasis.
● Primary adenocarcinoma may present as a small, barely detectable mass in the pancreatic head with enhancement similar to that of adjacent pancreatic parenchyma. Look for indirect findings of pancreatic duct obstruction or the double-duct sign (obstruction of the pancreatic and common bile ducts).
● Unresectability is suggested by invasion of adjacent organs, encasement or invasion of vascular structures, malignant ascites, and distant metastasis.
● Staging:
● Stage I: within pancreas
● Stage II: regional lymph nodes
● Stage III: distant metastases
● CT表现：胰腺癌常位于胰头（60%），中央可见低密度坏死区，胰周脂肪层消失，侵犯邻近器官（通常是十二指肠和胃），包裹并侵犯邻近血管、淋巴结，可发生远处转移。
● 原发性腺癌可能是胰头处一个小的，几乎不可察觉的肿块，增强类似于邻近胰腺实质。间接征象：胰管梗阻或双胰管征（胰腺和胆总管梗阻）。
● 无手术指征：侵犯邻近器官，包裹并侵犯血管结构，恶性腹水，远处转移。
● 分期：
● 第一阶段：胰腺内
● 第二阶段：区域淋巴结
● 第三阶段：远处转移
● Other Imaging Findings
● No Other Imaging Findings
● 其他影像检查：
● 无其他影像检查
● Pearls and Pitfalls
● Islet cell tumors are most commonly functional and markedly enhancing. Nonfunctional islet cell tumors typically present as larger masses but may occasionally present as smaller, locally invasive masses.
● Focal pancreatitis should be included in the differential diagnosis for a subtle pancreatic mass with biductal obstruction. Rank-order the differential based on the clinical presentation.
● Effacement of peripancreatic fat planes can be present on normal CT scans, particularly in patients with limited retroperitoneal fat. Look for thickening of the Gerota fascia.
● 要点及误区：
● 胰岛细胞瘤中，最常见的是功能性胰岛细胞瘤，增强扫描明显强化；非功能性胰岛细胞瘤常表现为较大的肿块，但有时可表现为较小的局部浸润性肿块。
● 鉴别诊断还应包括局灶性胰腺炎，表现为较小的胰腺肿块伴胰管梗阻。但因其临床表现而可能性较低。
● CT上可见胰周脂肪层消失，特别是腹膜后脂肪，并伴有肾前筋膜增厚。
● 参考文献：
● Kalra MK, Maher MM, Mueller PR, Saini S. State-of-the-art imaging of pancreatic neoplasms. Br J Radiol. 2003;76(912):857-865.