Aust. Radio1 (1977). 21, 140
An Unusual Tumour of the Lesser Sac H. C. MEREDITH,M.B.B.S.,M.R.A.C.R. IVAN VUJIC, M.D. A.M. MUNSTER, M.D. J. B. HOOD, M.D. Department of Radiology, Medical University of South Carolina CASE REPORT: The patient was a 15 year old Negro girl who presented with a slowly enlarging, mobile, firm, left upper quadrant mass, first noticed eighteen month's previously. There were no other relevant clinical or laboratory findings; in particular, no metabolic or hormonal abnormalities were found. The urogram showed under-filling of the superior pole of the left kidney which was not displaced. Renal angiography was normal. The splenic flexure and transverse colon were displaced inferiorly and' the stomach was displaced upwards and to the right (Figure 1). Radioisotope scan revealed a normal spleen. Ultrasound showed a fluid-filled structure with multiple septations. The relevant angiography is shown in figures 2, 3 and 4. The tumour was vascular in its upper quarter and the remainder was relatively avascular. I t displaced the coeliac axis and its branches upwards and to the right and caused stretching of the inferior branch of the splenic artery. The superior splenic artery branch was tortuous. A branch of the dorsal pancreatic artery thought to be in mesocolon was stretched around its inferior pole, and gave rise to several vessels which were stretched over the medial and lower poles of the tumour. This is an unexpected finding in the absence of tumour involvement in head or body of pancreas. These vessels were the main blood supply to the avascular lower part of the tumour. The main blood supply t o the vascular upper pole was via tumour vessels arising from branches of the splenic artery, particularly near the splenic hilus. No abnormality was shown in the'venous phase. The head and body of the pancreas were not REPRINT ADDRESS: Dr. H.C. Meredith M e d i i Univenity of South Carolina 17 1 Ashley Avenue Charkston. South Carolina 29403 Drs. Meredith, Vujic and Hood Assirrtpnt ~ofessorsof Radiology, Medical Uarvenity of South Carolina. Dr. Munster now Associate Professor of Surgery, The!ohns Hopkins University School of Medicine, Baitmore, Maryland 21224.
140
FIGURE 1.-Barium meal shows displacement of the stomach and jejunal loops by tumour in the upper quadrant .
thought to be involved by tumour and preoperatively a diagnosis of a largely cystic tumour arising in the region of the splenic hilus or tail of the pancreas were made. The mass was within the lesser sac and was approached through the gastro-colic omentum. I t was completely encapsulated and cystic and free of attachment to other intra-abdominal organs. It derived its blood supply through one major pedicle attached to the gastro-colic omenturn, with a number of minor vascular attachments within the lesser sac. The pancreas was clearly separate from the mass. Key Words: Papillary cystadenom; Aberrant pancreas;
Lesser sac, Coeliac angiography.
Australasian Radiology, VoL XXI, No. 2, June, 1977
AN UNUSUAL TUMOUR OF THE LESSER SAC
FIGURE 2,-Coeliac Angiogram - Arterial phase shows stretching and displacement of coeliac, splenic and left gastric vessels. Open arrow indicates right gastroepiploic artery. Arrowhead shows branch of dorsal pancreatic artery stretched around lower pole of tumour.
FIGURE 4.-Ce&c angiogrm - subtraction films in arterial phase show origin of dorsal pancreatic artery from coeliac axis giving rise to the vessel stretched around the Iowa pole of the tumour. Gastro-duodenal artery, open arrow.
malignancy. Normal islets were present in the capsule. The pedicle showed fibrous and vascular tissue with no evidence of tumour.
FIGURE 3.-Splenic angiogram - Subtraction films in arterial phase shows transverse pancreatic artery, open arrow. Main splenic artery branches, lower arrowheads. Tumour vessels in upper pole of tumour, upper arrowheads.
PA THOLOG Y: The specimen which measured 14 x 13.5 cm in size, had an intact membranous capsule, was multicystic and contained a large volume of haemorrhagic reddish/brown fluid. Histologically, the tumour was papillary and cystic, probably of small duct origin, either benign or of very low grade Australasian Radwlogy, VoL XXI, No. 2, June. I977
DISCUSSION: The incidence of heterotopic pancreas in surgical material has been variously reported as 1: 120 to 600 and at necroscopy from 0.6 to 5.6% with a slight male preponderance 2 or 3:1.5 Its etiology and pathogenesis have been well des~ribed.~ The various anatomical locations of this an0 m a l y ~ 3 ~have 9 ~ included stomach, duodenum and jejunum, which have accounted for 70% and Meckel's diverticulum for over 5%. Other sites have been gall bladder, common bile duct, oesophagus, lung and mediastinum. Its incidence in the abdomen outside of abdominal organs has been approximately 5% and have included mesentery, omentum, transverse mesocolon and umbilicat fistulae.' Heterotopic pancreatic tissue may undergo all of the pathological changes seen in normally located p a n ~ r e a s . ~A wide range of symptomatology, beyond the scope of this paper, has been descnied, depending on the situation. Over 50% of cases have been symptomless but its 141
H. C. MEREDITH, I. VUJIC, A.M. MUNSTER AND J. B. HOOD presentation as an abdominal mass, such as occurred in this case, has been rarely described.5 Pancreatic cystadenomas are rare tumours. Their clinical,pathological and radiological features have been de~cribed.l%~.~ Eighty percent present as an abdominal mass. The female:male incidence is 9: 1. They occur more commonly from the fifth decade onwards. Their average sue has been about 10 cm and they have usually been well encapsulated and embedded in pancreas, replacing pancreatic tissue, most frequently in the body or tail. Uncommonly, they have been pedunculated and attached to the pancreas by a stalk. The tumour in our patient was pedunculated, attached to the gastrocolic omentum by a narrow stalk and was separate from the pancreas. Most cystadenomas are hypervascular, but hypovascular tumours and tumours showing both cystic and vascular components have been described. ,6 Malignant transformation is thought t o occur rarely, but because of their vascular nature, the differentiation between benign and malignant tumours has proven difficult. Encasement of major branch vessels with enlargement of branches, a bizarre hypervascular appearance with large irregular vessels and deep staining have been found in benign lesions. The presence of marked truncation of vessels and marked irregu-
'
142
larity have been described as features of malignancy.' These latter appearanceswere not present in our patient. ABSTRACT A cystadenoma o f the lesser sac, arising in aberrant pancreatic tissue in a young black female is described. The radiological and pathological features of pancreatic heteropia and cystadenomas are discussed.
REFERENCES 1. Abrams, R. M. et a1 (1967). Angiographic studies of benign and malignant cystadenoma of the pancreas. Radiology, 89: 1028-1032. 2. Barbosa, J. I., et a1 (1946). Pancreatic Heterotopia. Surg. Gynec and Obst. 82: 527-542. 3. Bensen, R. E., et a1 (1947). Cystadenoma of the pancreas. Surgery. 21: 353-361. 4. Besemann, E. F. et al. (1969). The importance of Roentgenologic diagnosis of aberrant pancreatic tissue in the gastro-intestinal tract. Amer. J. Roent. 107: 71-76. 5. Mobini, J., et al. (1974). Intrahepatic pancreatic heterotopia. Digestive Diseases. 19: 6 4 6 9 . 6. Pressman, B. D., et a1 (1973). Cystadenoma of the pancreas. Amer. J. Roent. 119: 115-120. 7. Review article. (1970) Scand. J. of Gastro-Ent. 5: 629-640.
Australasian Radiology, VoL XXI, No. 2, June, 1977
An Unusual Tumour of the Lesser Sac H. C. MEREDITH,M.B.B.S.,M.R.A.C.R. IVAN VUJIC, M.D. A.M. MUNSTER, M.D. J. B. HOOD, M.D. Department of Radiology, Medical University of South Carolina CASE REPORT: The patient was a 15 year old Negro girl who presented with a slowly enlarging, mobile, firm, left upper quadrant mass, first noticed eighteen month's previously. There were no other relevant clinical or laboratory findings; in particular, no metabolic or hormonal abnormalities were found. The urogram showed under-filling of the superior pole of the left kidney which was not displaced. Renal angiography was normal. The splenic flexure and transverse colon were displaced inferiorly and' the stomach was displaced upwards and to the right (Figure 1). Radioisotope scan revealed a normal spleen. Ultrasound showed a fluid-filled structure with multiple septations. The relevant angiography is shown in figures 2, 3 and 4. The tumour was vascular in its upper quarter and the remainder was relatively avascular. I t displaced the coeliac axis and its branches upwards and to the right and caused stretching of the inferior branch of the splenic artery. The superior splenic artery branch was tortuous. A branch of the dorsal pancreatic artery thought to be in mesocolon was stretched around its inferior pole, and gave rise to several vessels which were stretched over the medial and lower poles of the tumour. This is an unexpected finding in the absence of tumour involvement in head or body of pancreas. These vessels were the main blood supply to the avascular lower part of the tumour. The main blood supply t o the vascular upper pole was via tumour vessels arising from branches of the splenic artery, particularly near the splenic hilus. No abnormality was shown in the'venous phase. The head and body of the pancreas were not REPRINT ADDRESS: Dr. H.C. Meredith M e d i i Univenity of South Carolina 17 1 Ashley Avenue Charkston. South Carolina 29403 Drs. Meredith, Vujic and Hood Assirrtpnt ~ofessorsof Radiology, Medical Uarvenity of South Carolina. Dr. Munster now Associate Professor of Surgery, The!ohns Hopkins University School of Medicine, Baitmore, Maryland 21224.
140
FIGURE 1.-Barium meal shows displacement of the stomach and jejunal loops by tumour in the upper quadrant .
thought to be involved by tumour and preoperatively a diagnosis of a largely cystic tumour arising in the region of the splenic hilus or tail of the pancreas were made. The mass was within the lesser sac and was approached through the gastro-colic omentum. I t was completely encapsulated and cystic and free of attachment to other intra-abdominal organs. It derived its blood supply through one major pedicle attached to the gastro-colic omenturn, with a number of minor vascular attachments within the lesser sac. The pancreas was clearly separate from the mass. Key Words: Papillary cystadenom; Aberrant pancreas;
Lesser sac, Coeliac angiography.
Australasian Radiology, VoL XXI, No. 2, June, 1977
AN UNUSUAL TUMOUR OF THE LESSER SAC
FIGURE 2,-Coeliac Angiogram - Arterial phase shows stretching and displacement of coeliac, splenic and left gastric vessels. Open arrow indicates right gastroepiploic artery. Arrowhead shows branch of dorsal pancreatic artery stretched around lower pole of tumour.
FIGURE 4.-Ce&c angiogrm - subtraction films in arterial phase show origin of dorsal pancreatic artery from coeliac axis giving rise to the vessel stretched around the Iowa pole of the tumour. Gastro-duodenal artery, open arrow.
malignancy. Normal islets were present in the capsule. The pedicle showed fibrous and vascular tissue with no evidence of tumour.
FIGURE 3.-Splenic angiogram - Subtraction films in arterial phase shows transverse pancreatic artery, open arrow. Main splenic artery branches, lower arrowheads. Tumour vessels in upper pole of tumour, upper arrowheads.
PA THOLOG Y: The specimen which measured 14 x 13.5 cm in size, had an intact membranous capsule, was multicystic and contained a large volume of haemorrhagic reddish/brown fluid. Histologically, the tumour was papillary and cystic, probably of small duct origin, either benign or of very low grade Australasian Radwlogy, VoL XXI, No. 2, June. I977
DISCUSSION: The incidence of heterotopic pancreas in surgical material has been variously reported as 1: 120 to 600 and at necroscopy from 0.6 to 5.6% with a slight male preponderance 2 or 3:1.5 Its etiology and pathogenesis have been well des~ribed.~ The various anatomical locations of this an0 m a l y ~ 3 ~have 9 ~ included stomach, duodenum and jejunum, which have accounted for 70% and Meckel's diverticulum for over 5%. Other sites have been gall bladder, common bile duct, oesophagus, lung and mediastinum. Its incidence in the abdomen outside of abdominal organs has been approximately 5% and have included mesentery, omentum, transverse mesocolon and umbilicat fistulae.' Heterotopic pancreatic tissue may undergo all of the pathological changes seen in normally located p a n ~ r e a s . ~A wide range of symptomatology, beyond the scope of this paper, has been descnied, depending on the situation. Over 50% of cases have been symptomless but its 141
H. C. MEREDITH, I. VUJIC, A.M. MUNSTER AND J. B. HOOD presentation as an abdominal mass, such as occurred in this case, has been rarely described.5 Pancreatic cystadenomas are rare tumours. Their clinical,pathological and radiological features have been de~cribed.l%~.~ Eighty percent present as an abdominal mass. The female:male incidence is 9: 1. They occur more commonly from the fifth decade onwards. Their average sue has been about 10 cm and they have usually been well encapsulated and embedded in pancreas, replacing pancreatic tissue, most frequently in the body or tail. Uncommonly, they have been pedunculated and attached to the pancreas by a stalk. The tumour in our patient was pedunculated, attached to the gastrocolic omentum by a narrow stalk and was separate from the pancreas. Most cystadenomas are hypervascular, but hypovascular tumours and tumours showing both cystic and vascular components have been described. ,6 Malignant transformation is thought t o occur rarely, but because of their vascular nature, the differentiation between benign and malignant tumours has proven difficult. Encasement of major branch vessels with enlargement of branches, a bizarre hypervascular appearance with large irregular vessels and deep staining have been found in benign lesions. The presence of marked truncation of vessels and marked irregu-
'
142
larity have been described as features of malignancy.' These latter appearanceswere not present in our patient. ABSTRACT A cystadenoma o f the lesser sac, arising in aberrant pancreatic tissue in a young black female is described. The radiological and pathological features of pancreatic heteropia and cystadenomas are discussed.
REFERENCES 1. Abrams, R. M. et a1 (1967). Angiographic studies of benign and malignant cystadenoma of the pancreas. Radiology, 89: 1028-1032. 2. Barbosa, J. I., et a1 (1946). Pancreatic Heterotopia. Surg. Gynec and Obst. 82: 527-542. 3. Bensen, R. E., et a1 (1947). Cystadenoma of the pancreas. Surgery. 21: 353-361. 4. Besemann, E. F. et al. (1969). The importance of Roentgenologic diagnosis of aberrant pancreatic tissue in the gastro-intestinal tract. Amer. J. Roent. 107: 71-76. 5. Mobini, J., et al. (1974). Intrahepatic pancreatic heterotopia. Digestive Diseases. 19: 6 4 6 9 . 6. Pressman, B. D., et a1 (1973). Cystadenoma of the pancreas. Amer. J. Roent. 119: 115-120. 7. Review article. (1970) Scand. J. of Gastro-Ent. 5: 629-640.
Australasian Radiology, VoL XXI, No. 2, June, 1977
![[Cystic lymphangioma of the lesser sac].](/assets/img/hold.png)
