Mass forming chronic pancreatitis mimicking pancreatic cystic neoplasm: A case report

Abstract

Mass forming chronic pancreatitis is very rare. Diagnosis could be done by the pathologic findings of focal inflammatory fibrosis without evidence of tumor in pancreas. A 34-year-old man presented with right upper abdominal pain for a few weeks and slightly elevated bilirubin level on clinical findings. Radiological findings of multidetector-row computed tomography, magnetic resonance (MR) imaging with MR cholangiopancreatography and endoscopic ultrasonography revealed focal branch pancreatic duct dilatation with surrounding delayed enhancing solid component at uncinate process and head of pancreas, suggesting branch duct type intraductal papillary mucinous neoplasm. Surgery was done and pathology revealed the focal chronic inflammation, fibrosis, and branch duct dilatation. Herein, I would like to report the first case report of mass forming chronic pancreatitis mimicking pancreatic cystic neoplasm.

Full text

World Journal of
Gastroenterology
World J Gastroenterol 2018 January 14; 24(2): 161-314
ISSN 1007-9327 (print)
ISSN 2219-2840 (online)
Published by Baishideng Publishing Group Inc

S
MINIREVIEWS
161 Drug-eluting beads transarterial chemoembolization for hepatocellular carcinoma: Current state of the art
Facciorusso A
ORIGINAL ARTICLE
Basic Study
170 AntibrogeniceffectsofvitaminDderivativesonmousepancreaticstellatecells
Wallbaum P, Rohde S, Ehlers L, Lange F, Hohn A, Bergner C, Schwarzenböck SM, Krause BJ, Jaster R
179 Metabolicandhepaticeffectsofliraglutide,obeticholicacidandelabranorindiet-inducedobesemouse
modelsofbiopsy-conrmednonalcoholicsteatohepatitis
Tølbøl KS, Kristiansen MNB, Hansen HH, Veidal SS, Rigbolt KTG, Gillum MP, Jelsing J, Vrang N, Feigh M
195 INT-767improveshistopathologicalfeaturesinadiet-induced
ob/ob
mousemodelofbiopsy-conrmednon-
alcoholic steatohepatitis
Roth JD, Feigh M, Veidal SS, Fensholdt LKD, Rigbolt KT, Hansen HH, Chen LC, Petitjean M, Friley W, Vrang N, Jelsing J,
Young M
211 Novelconceptofendoscopicdevicedeliverystationsystemforrapidandtightattachmentofpolyglycolic
acid sheet
Mori H, Kobara H, Nishiyama N, Masaki T
216 β-arrestin2attenuateslipopolysaccharide-inducedliverinjury
via
inhibition of TLR4/NF-kB signaling
pathway-mediatedinammationinmice
Jiang MP, Xu C, Guo YW, Luo QJ, Li L, Liu HL, Jiang J, Chen HX, Wei XQ
226 HepatitisCviruscoreprotein-inducedmiR-93-5pup-regulationinhibitsinterferonsignalingpathwayby
targeting IFNAR1
He CL, Liu M, Tan ZX, Hu YJ, Zhang QY, Kuang XM, Kong WL, Mao Q
237 Transplantationofbonemarrow-derivedendothelialprogenitorcellsandhepatocytestemcellsfromliver
brosisratsamelioratesliverbrosis
Lan L, Liu R, Qin LY, Cheng P, Liu BW, Zhang BY, Ding SZ, Li XL
Case Control Study
248 Geneticvariantsofinterferonregulatoryfactor5associatedwithchronichepatitisBinfection
Sy BT, Hoan NX, Tong HV, Meyer CG, Toan NL, Song LH, Bock CT, Velavan TP
Contents Weekly Volume 24 Number 2 January 14, 2018
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Contents World Journal of Gastroenterology
Volume 24 Number 2 January 14, 2018
Retrospective Study
257 Timingofsurgeryafterneoadjuvantchemotherapyforgastriccancer:Impactonoutcomes
Liu Y, Zhang KC, Huang XH, Xi HQ, Gao YH, Liang WQ, Wang XX, Chen L
266 PredictiveandprognosticvalueofserumAFPlevelanditsdynamicchangesinadvancedgastriccancer
patientswithelevatedserumAFP
Wang YK, Zhang XT, Jiao X, Shen L
SYSTEMATIC REVIEWS
274 Neoadjuvantchemotherapyforgastriccancer.Isitamustorafake?
Reddavid R, Soa S, Chiaro P, Colli F, Trapani R, Esposito L, Solej M, Degiuli M
CASE REPORT
290 Clinically diagnosed late-onset fulminant Wilson’s disease without cirrhosis: A case report
Amano T, Matsubara T, Nishida T, Shimakoshi H, Shimoda A, Sugimoto A, Takahashi K, Mukai K, Yamamoto M, Hayashi S,
Nakajima S, Fukui K, Inada M
297 Massformingchronicpancreatitismimickingpancreaticcysticneoplasm:Acasereport
Jee KN
303 Successfultreatmentofagiantossiedbenignmesentericschwannoma
Wu YS, Xu SY, Jin J, Sun K, Hu ZH, Wang WL
LETTER TO THE EDITOR
310
Candida
accommodates non-culturable
Helicobacter pylori
initsvacuole-Koch’spostulatesaren’tapplicable
Siavoshi F, Saniee P
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NAME OF JOURNAL
World Journal of Gastroenterology
ISSN
ISSN 1007-9327 (print)
ISSN 2219-2840 (online)
LAUNCH DATE
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gery, Fundacion Jimenez Diaz University Hospital,
Madrid 28040, Spain
Stephen C Strom, PhD, Professor, Department of
Laboratory Medicine, Division of Pathology, Karo-
linska Institutet, Stockholm 141-86, Sweden
Andrzej S Tarn awski , MD, PhD, DSc (Med),
Professor of Medicine, Chief Gastroenterology, VA
Long Beach Health Care System, University of Cali-
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World Journal of Gastroenterology
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Mass forming chronic pancreatitis mimicking pancreatic
cystic neoplasm: A case report
Keum Nahn Jee
Keum Nahn Jee, Department of Radiology, Dankook University
Hospital, Chungcheongnam-do 330-715, South Korea
ORCID number: Keum Nahn Jee: (0000-0003-2669-4381).
Author contributions: Jee KN designed the report, collected
the patient’s clinical data, drafting the article and reviewed the
manuscript and approved the nal manuscript as submitted.
Informed consent statement: This study was reviewed and
approved the retrospective case review by Institutional Review
Board of Dankook University Hospital, Cheonan, South Korea,
with informed consent from the patient waived.
Conict-of-interest statement: There are no potential conicts
(financial, professional, or personal) of interest relevant to this
article to disclose by the author.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Manuscript source: Unsolicited manuscript
Correspondence to: Keum Nahn Jee, MD, PhD, Professor,
Department of Radiology, Dankook University Hospital,
Mang-hyang Street 201, Anseo-dong, Dongnam-gu, Cheonan,
Chungcheongnam-do 330-715,
South Korea. jkn1303@dkuh.co.kr
Telephone: +82-41-5506921
Fax: +82-41-5529674
Received: October 19, 2017
Peer-review started: October 20, 2017
First decision: November 8, 2017
Revised: November 15, 2017
Accepted: November 22, 2017
Article in press: November 22, 2017
Published online: January 14, 2018
Abstract
Mass forming chronic pancreatitis is very rare.
Diagnosis could be done by the pathologic findings
of focal inflammatory fibrosis without evidence of
tumor in pancreas. A 34-year-old man presented
with right upper abdominal pain for a few weeks and
slightly elevated bilirubin level on clinical findings.
Radiological findings of multidetector-row computed
tomography, magnetic resonance (MR) imaging
with MR cholangiopancreatography and endoscopic
ultrasonography revealed focal branch pancreatic duct
dilatation with surrounding delayed enhancing solid
component at uncinate process and head of pancreas,
suggesting branch duct type intraductal papillary
mucinous neoplasm. Surgery was done and pathology
revealed the focal chronic inflammation, fibrosis, and
branch duct dilatation. Herein, I would like to report the
first case report of mass forming chronic pancreatitis
mimicking pancreatic cystic neoplasm.
Key words: Chronic pancreatitis; Pseudotumor; Com-
puted tomography; Magnetic resonance imaging; En-
doscopic ultrasound
© The Author(s) 2018. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: Extremely unusual radiological manifestation
of ma ss form ing chroni c pancreat itis mimic king
pancreatic cystic neoplasm is the rst case report in the
English-written medical literature.
Jee KN. Mass forming chronic pancreatitis mimicking pancreatic
cystic neoplasm: A case report. World J Gastroenterol 2018;
CASE REPORT
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Submit a Manuscript: http://www.f6publishing.com
DOI: 10.3748/wjg.v24.i2.297
World J Gastroenterol 2018 January 14; 24(2): 297-302
ISSN 1007-9327 (print) ISSN 2219-2840 (online)

24(2): 297-302 Available from: URL: http://www.wjgnet.
com/1007-9327/full/v24/i2/297.htm DOI: http://dx.doi.
org/10.3748/wjg.v24.i2.297
INTRODUCTION
Chronic pancreatitis represents a recurrent, prolonged
inflammatory process and progressive fibrosis of the
pancreas. These results in irreversible morphologic
change of the pancreas, clinical symptoms of abdominal
pain, and insufficiency of exocrine and endocrine
function[1-3]. On computed tomography (CT) and ma-
gnetic resonance (MR) image, dilatation of the main
pancreatic duct, parenchymal atrophy, pancreatic ca-
lcification or stone, focal pancreatic enlargement or
inflammatory pancreatic mass, bile duct dilatation,
attenuation change of peripancreatic fat and fluid colle
ction are frequent findings[4-6].
Inflammatory mass in chronic pancreatitis retain a
large degree of fibrosis like pancreatic carcinoma[7-9],
and both lesions are shown as a gradual progressive
enhancement on contrast-enhanced CT and dynamic
MR imaging, making the discrimination of the two
entities difficult[5,6,10].
In the case of mass forming chronic pancreatitis,
diagnosis of inflammatory pancreatic mass could be
almost impossible if associated radiological findings of
chronic pancreatitis is not shown.
This paper presents a very unique case of mass
forming chronic pancreatitis mimicking pancreatic
cystic neoplasm.
CASE REPORT
A 34-year-old man complained for right upper abdominal
pain for a few days. His laboratory findings including
white blood cell count, C-reactive protein, alkaline
phosphatase, liver enzyme level and tumor markers
of carbohydrate antigen 19-9 and carcinoembryonic
antigen were within normal range except slight elevation
of total bilirubin (1.3 mg/dL, normal range of 0.2-1.2),
gamma-glutamyl transferase (108 IU/L, normal range
of 8-60) and lipase (90 U/L, normal range of 30-60).
The patient had past medical history of admission due
to acute alcoholic pancreatitis 13 years ago and social
history of daily alcohol consumption for 15 years and
having smoked 20 pack years.
Unenhanced abdomen CT image showed slight low
attenuating lesion involving pancreatic uncinate process
and head (Figure 1A). Contrast-enhanced abdominal
CT images showed a delayed enhancing solid portion
surrounding a few tubular cystic attenuating lesion
sized about 2.5 cm × 2.1 cm in pancreatic uncinate
process and head, and mild dilatation of common bile
duct (CBD) and gallbladder (Figure 1B and C). MR
cholangiopancreatography showed branch pancreatic
duct dilation in head and uncinate process causing
extrinsic indentation and tapering of distal CBD, and mild
dilatation of proximal CBD and gallbladder (Figure 2A).
Fat-saturated T2-weighted MR image showed a slight
high signal intensity solid component surrounding bright
signal intensity branch duct dilatation in pancreatic
uncinate process and head, with the lesion sized about
2.6 cm × 2.2 cm (Figure 1B). Fat-suppressed T1-
weighted MR image showed a well-demarcated low
signal intensity lesion in head and uncinate process of
pancreas (Figure 2C), and delayed contrast-enhancing
solid component surrounding low signal intensity branch-
duct dilation in pancreatic uncinate process and head
was shown on fat-suppressed T1-weighted dynamic
gadolinium-enhanced MR images (Figure 2D and E).
Diffusion-weighted MR images showed higher signal
intensity on low b factor (b = 20 s/m2) image and low
signal intensity on high b factor (b = 800 s/m2) image,
suggesting no diffusion restriction on apparent diffusion
coefficient map (Figure 2H), which reflecting the large
area of cystic component of the lesion. Endoscopic
ultrasonography (EUS) showed pruning pattern,
anechoic branch duct dilatation containing a few small
hyperechoic mural nodules (Figure 3A and B).
The lesion located in uncinate process and head of
pancreas with indenting distal CBD and dilatation of
proximal CBD, without dilatation of main pancreatic duct
due to anatomic variation of pancreatic divisum which
was detected on MR image (Figure 2B). Radiological
diagnostic impression was branch duct type intraductal
papillary mucinous neoplasm (IPMN) of pancreas.
However, some worrisome features of delayed contrast-
enhancing solid component around the wall of dilated
branch duct on CT and MR images and small mural
nodules in dilated branch ducts on EUS were shown.
EUS guided fine needle aspiration (FNA) cytology was
obtained from the solid component along the wall of
dilated duct and suggested the possibility of intraductal-
growing epithelial neoplasm.
The patient underwent pylorus-preserving pan-
creaticoduodenectomy, due to considering FNA finding,
imaging findings of CT, MRI, and EUS and aggravated
right upper abdominal pain and persistent mild elevation
of bilirubin and gamma-glutamyl transferase levels
without response to conservative medical treatment for
four weeks. The gross pathology of resected specimen
showed whitish hard infiltrating lesion in pancreatic
uncinate process and head portion (Figure 4A). The
histopathologic report revealed periductal inflammation
with fibrosis and mild dilatation of branch pancreatic
ducts and intralobular fibrosis, consistent with chronic
pancreatitis (Figure 4B).
DISCUSSION
Chronic pancreatitis is defined as inflammatory and
fibrotic disease of pancreatic tissue, characterized
by irreversible functional and morphologic change.
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Jee KN. Mass forming chronic pancreatitis

Alcohol abuse is the most common (70%-80%) cause
of chronic pancreatitis in the developed countries[1,2,3,7].
In addition, smoking, gene mutations, autoimmune
syndromes, metabolic disturbances, environmental
conditions and anatomical abnormalities are suggested
as other associated factors with occurrence of the
disease[3,11,12].
The pathology of advanced alcoholic chronic pan-
creatitis revealed a firm consistency of pancreas with
an irregular contour without the normal lobulation[13].
The fibrosis may diffusely affect the entire gland, but
occasionally it is unevenly distributed, with preserved
normal lobular pattern in some areas. The severity
of the duct changes depends on the extent of the
surrounding fibrosis. Thus, the main duct may be focally
or diffusely involved with obstruction, irregular dilatation
and distortion[14,15]. Fibrosis in the pancreas head may
cause a tapering stenosis of CBD[16].
In this case, initial clinical symptom of right upper
abdominal pain was developed due to dilatation of
gallbladder by stenosis of distal CBD, and the causative
lesion of CBD obstruction was a focal mass lesion,
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A B C
Figure 1 Findings from computed tomography. A: Unenhanced computed tomography (CT) image shows a slight low attenuating lesion (arrow) in pancreatic
uncinated process and head and dilatation of gallbladder; B: Contrast-enhanced arterial phase CT image shows minimal enhancing low attenuating lesion (long arrow)
surrounding a few tubular low cystic attenuating structures (short arrow), and homogenous highly enhancing normal pancreas (arrowhead); C: Contrast-enhanced
portal venous phase CT image shows delayed enhancing lesion (long arrow) containing a few tubular cystic structures (short arrow).
Figure 2 Findings from magnetic resonance image. A: Magnetic resonance (MR) cholangiopancreatography shows localized branch pancreatic duct dilatation (short
arrow) in head of pancreas with tapering of distal common bile duct and dilatation of proximal common duct (long arrow); B: T2-weighted MR image shows slight high
signal intensity lesion (long arrow) containing bright intensity branch duct dilatation (short arrow) in head and uncinate process of pancreas, and incidental nding
of pancreatic divisum (arrowhead); C: Fat-suppressed T1-weighted MR image shows a well-demarcated low signal intensity lesion (long arrow) in uncinate process
and head of pancreas; D-E: Fat-suppressed T1-weighted gadolinium-enhanced arterial- (D) and delayed-phase (E) MR images show delayed highly enhancing solid
mass-like lesion (long arrows) containing non-enhancing dark intensity branch duct dilatation (short arrows) in pancreatic head; F: The higher signal intensity lesion
(arrow) on diffusion-weighted image obtained with b = 20 s/m2 shows as low signal intensity (arrow) on diffusion-weighted image obtained with b = 800 s/m2 and as
higher (arrow) apparent diffusion coefcient (ADC) without diffusion restriction.
EF
A B C D
b
= 20 ADC
G H
b
= 800
Jee KN. Mass forming chronic pancreatitis

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CT in spectral imaging mode, 18F fluorodeoxyglucose
positron emission tomography/CT combined with
carbohydrate antigen 19-9, and quantitative endoscopic
ultrasound elastography, but still it is very difficult to
distinguish accurately between the two[5,10,20-24]. MRI is
much better than CT for detection and characterization
of focal pancreatic lesion, but it could not differentiate
mass forming chronic pancreatitis from pancreatic
carcinoma, even using diffusion-weighted functional
MR imaging technique[5,10,25,26]. In addition, none of the
above mentioned papers included a case of a solid mass
containing cystic lesion like this in their research of
differentiation between mass forming pancreatitis and
pancreatic carcinoma.
Among the papers on relationship between main
pancreatic duct (MPD) and the mass, the “duct-penetrating”
sign of MPD on MR cholangiopancreatography was
reported to be helpful with relatively high sensitivity and
specificity, and the result was smoothly stenotic or normal
MPD penetrating a mass was seen more frequently
in inflammatory pancreatic mass than in pancreatic
carcinoma[27]. However, in this peculiar case, inflammatory
mass possessed dilated branch pancreatic duct without
stenosis.
In this very unique case, it could be comprehended
including branch duct dilatation with surrounding solid
component in uncinate process and head of pancreas,
detected on CT, MRI and EUS findings. The diagnostic
impression based on radiological imaging findings
was branch duct type IPMN most likely and serous
cystadenoma as a possible differential diagnosis.
In thinking of branch duct type IPMN, analyses of
imaging findings included the “worrisome features” of
contrast-enhancing ductal margin on CT and MRI and
mural nodules in dilated duct on EUS[17-19]. In addition,
FNA suggested intraductal-growing epithelial neoplasm
though scant cellularity. Surgery was the best choice
at that time, considering aggravated clinical symptom,
radiological findings, opinion of FNA, and patient’s
young age. However, final pathologic result revealed
interlobular and intralobular inflammation and fibrosis
associated with branch duct dilatation, compatible with
chronic pancreatitis. It was a totally unexpected one,
even though considering patient’s past medical history
of severe alcoholic pancreatitis and social history of
frequent alcohol consumption and heavy smoking.
There have been many reports for the differentiation
mass forming chronic pancreatitis from pancreatic
adenocarcinoma such as dynamic enhancement of CT
and MR imaging, Perfusion CT imaging, duel energy
A B
CBD
Figure 3 Findings from endoscopic ultrasound. A: EUS shows a few anechoic tubular structures (arrows), causing indentation of distal CBD and dilatation of
proximal bile duct; B: EUS shows small hyperechoic mural nodules (arrows) in the dilated branch pancreatic ducts. EUS: Endoscopic ultrasound; CBD: Common bile
duct.
A B
Figure 4 Macroscopic and microscopic ndings of resected specimen. A: Gross specimen shows whitish hard inltrating mass-like lesion (arrows) focally
replaced head and uncinate process of pancreas; B: Microscopy (hematoxylin and eosin, x 40) shows perilobular and intralobular brosis (asterisk) replaces normal
pancreatic acini with focal perivascular lymphocyte inltration (short arrow) and dilated branch ducts (long arrows).
*
Jee KN.
Mass forming chronic pancreatitis

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uneven fibrosis and inflammation developed in localized
area of uncinate process and head of pancreas, focal
severe perilobular and interlobular fibrosis caused
stricture and dilatation of branch pancreatic duct in
uncinate process, and the these outbreaks led to very
distinctive and peculiar radiological features of mass
forming chronic pancreatitis and clinical symptoms of
bile duct obstruction.
There has been no literature about focal fibrotic
mass forming chronic pancreatitis containing branch
duct dilatation, and incidentally this lesion showed
almost typical imaging findings of pancreatic cystic
neoplasm.
ARTICLE HIGHLIGHTS
Case characteristics
A 34-year-old man was referred to our hospital with right upper abdominal pain,
and a pancreatic solid and cystic lesion found on computed tomography (CT),
magnetic resonance (MR) image with MR cholangiography, and endoscopic
ultrasonography (EUS).
Clinical diagnosis
Branch duct type intraductal papillary mucinous neoplasm.
Differential diagnosis
Serous cystadenoma among solid and cystic pancreatic neoplasms.
Laboratory diagnosis
Abnormal laboratory results included slightly elevated level of total bilirubin (1.3
mg/dL, normal range of 0.2-1.2) and gamma-glutamyl transferase (108 IU/L,
normal range of 8-60).
Imaging diagnosis
CT and MR imaging showed a delayed contrast-enhanced solid lesion
containing pruning-pattern branch duct dilatation in uncinate process and head
of pancreas, with small hyperechoic mural nodules in the dilated branch ducts
on EUS.
Pathological diagnosis
Microscopic findings of resected specimen revealed mass forming chronic
pancreatitis including branch duct dilatation.
Treatment
The patient was treated with pylorus-preserving pancreaticoduodenectomy.
Related reports
There have been many reports for the discrimination between mass forming
chronic pancreatitis and pancreatic adenocarcinoma using various imaging
modalities.
Term explanation
There are no non-standard medical terms used in this manuscript.
Experiences and lessons
The author presents this case to share the very unusual but important
knowledge that mass forming chronic pancreatitis might include the branch duct
dilatation.
ACKNOWLEDGEMENTS
I wish to thank to Drs. Sung Ho Cho (Department of
Surgery, Dankook University Hospital) and Won-Ae
Lee (Department of Pathology, Dankook University
Hospital) for their comments and discussions about
the case.
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ARTICLE HIGHLIGHTS
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P- Reviewer: Agrawal S, Tandon RK S- Editor: Chen K
L- Editor: A E- Editor: Ma YJ
Jee KN. Mass forming chronic pancreatitis

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