25 | Abdominal Key

History

A 60-year-old lady with a past history of diabetes mellitus and chronic hepatitis B presents with progressive weight loss of 2kg over 3 months associated with non-specific abdominal discomfort. She is a non-drinker.

Physical examination

•Afebrile, pulse 80 bpm, BP 120/80mmHg, SaO₂ 98-100% on RA.

•Hydration is satisfactory.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable.

•Cardiovascular: HS dual, no murmur.

•Her chest is clear on auscultation.

•Abdominal examination reveals a soft, non-tender abdomen, with no peritoneal signs.

•No signs of oedema.

Investigations

•CBC:

–WBC 6.2 x 10⁹/L;

–haemoglobin 12.3g/dL;

–platelets 262 x 10⁹/L.

A computed tomography scan is performed (Figure 25.1).

Please describe what you see

A cystic lesion is noted at the pancreatic tail (circle). There are irregular peripheral calcifications noted.

What is your differential diagnosis?

•Mucinous cystic neoplasm (MCN).

•Serous cystic neoplasm (SCN).

•Intraductal papillary mucinous neoplasm (IPMN).

How would you proceed?

As the diagnosis is not clear at this juncture, further investigation with endoscopic ultrasound (EUS) (Figure 25.2) would be helpful in differentiating the various types of pancreatic cystic neoplasms. This could be achieved by the ultrasonographic appearance, together with EUS-guided fine-needle aspiration for cytology (FNAC) and cyst fluid analysis.

Please describe what you see

There is a 4.2cm x 2.8cm well defined cystic lesion with a few septations at the pancreatic tail. Fine-needle aspiration is performed which reveals that the fluid is compatible with cystic fluid, but no epithelial lining or malignant cells could be found.

Does this narrow the differential?

Thin septations are usually found in mucinous cystic neoplasms.

What would you do next?

In view of the suspected mucinous cystic neoplasm, the large size of the lesion, accompanied by constitutional symptoms of weight loss, in a woman with a relatively good functional status, she is referred to the surgical department for resection.

What is the final pathological diagnosis?

The following histological images are shown in Figures 25.3

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