Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

Hradec Králové, Czech Republic

Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

Filip ?e?ka, Alexander Ferko, Bohumil Jon, Zdeněk ?ubrt, Petra Ka?parová and Rudolf Repák

Hradec Králové, Czech Republic

BACKGROUND:Castleman disease is an uncommon lymphoproliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature.

METHOD:This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection.

RESULTS:A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fi ne needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease.

CONCLUSIONS:Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fi stula.

(Hepatobiliary Pancreat Dis Int 2013;12:332-334)

Castleman disease;pancreas; laparoscopic distal pancreatectomy; Ligasure

Introduction

Tumors in the body and tail of the pancreas are often asymptomatic or may present with vague and indistinctive abdominal pain. A list of the most common diagnoses of masses in the body and tail of the pancreas include adenocarcinoma, cystic tumors, and functioning or non-functioning neuroendocrine tumors. Other fi ndings such as Castleman disease are quite rare. The authors report a rare case of pancreatic Castleman disease treated with laparoscopic distal pancreatectomy.

Case report

A 48-year-old woman presented with epigastric pain. The pain was temporary with prompt relief after analgesia. Contrast enhanced CT scan (Fig. 1) revealed a well-encapsulated mass 37×37 mm on the ventral border of the pancreas. The CT scan also showed suspicion of inf i ltration of the gastric wall, indicating an origin from the muscular layer of the gastric wall (e.g. gastrointestinal stromal tumor (GIST)). Endosonography showed a mass 38×26 mm located between the pancreas and gastric wall (Fig. 2). However, it could notconf i rm the origin of the tumor. Fine-needle aspiration biopsy showed lymphoid elements, structures of a normal lymph node and structures of clear cylindrical epithelium without dysplasia, possibly originating from a benign mucinous tumor. After preoperative diagnosis, a differential diagnosis was made between a cystic tumor of the pancreas, GIST originating from the gastric wall, or an enlarged lymph node. Laparoscopic exploration and resection of the tumor were decided.

Fig. 1.Contrast enhanced CT scan showing a well-encapsulated mass of 37×37 mm on the ventral border of the pancreas. The black arrow points at the tumor.

Fig. 2.Endosonography showing a mass of 38×26 mm located between the pancreas and gastric wall. The needle for the aspiration biopsy is visible in the tumor.

Fig. 3.Laparoscopic intraoperative image. The black arrow points at the tumor on the ventral border of the pancreas

Fig. 4.Histologically, the surgical specimen showing a lymphatic node with angiofolicular hyperplasia-hyaline-vascular type of Castleman disease (Hematoxylin-eosin staining, original magnif i cation ×40).

During the laparoscopic exploration, a lesser sac was opened through division of the gastrocolic ligament. A tumor was found on the ventral border of the pancreas; it did not cohere to the gastric wall (Fig. 3). Laparoscopic resection was made of the tail of the pancreas with the tumor. The pancreas between the body and tail was transected with a Ligasure device. Afterwards, the pancreatic stump was secured with a manual suture. In the postoperative course, a type A pancreatic fi stula (according to International Study Group on Pancreatic Fistula) was observed.[1]No other complications in the postoperative course were noted and the patient was discharged from the hospital on the seventh postoperative day. A fi nal histological examination showed a fi nding typical for Castleman disease: an enlarged intrapancreatic lymphatic node with angiofolicular hyperplasia - hyaline-vascular type (Fig. 4). The patient is now being followed up at our department and is complaint-free, showing no signs of recurrence of the disease one year after the surgery.

Discussion

Castleman disease is a relatively rare disorder characterized by benign proliferation of lymphoid tissue. Its precise incidence is unknown.[2]It was fi rst described by Castleman et al in 1954.[3]There are two histological types of the disease.[4]The more frequent type is the hyaline-vascular type (85%-90% of cases), which is characterized by abnormal lymphoid follicles, numerous vessels, and wide fi brous septa. The disease is usually asymptomatic. The plasma-cell type is less frequent (10%-15%); it is characterized by large follicles with intervening sheets of plasma cells and few vessels.

Castleman disease commonly occurs in the mediastinum (60%-70% of cases). Abdominal forms are less frequent (10%-17%), and the majority of them are retroperitoneal.[5]Other locations are less common. Pancreatic Castleman disease is extremely rare, with only 17 cases having been described in the literature so

Little is known about the etiology of the disease.[2,21]A recent report[22]suggest the association of Castleman disease with HHV-8 and HIV infections. However, the sources of immune activation in the HHV-8 and HIV negative patients are still unidenti fi ed. Other exogenous and endogenous factors may induce IL-6 secretion from B-lymphocytes. Local production of IL-6 may contribute to the characteristic B-cell proliferation and vascularization.[23]Moreover, in patients with multicentric Castleman disease, systemic symptoms may result from increased production and circulation ofIL-6.[23]

The main issue in pancreatic Castleman disease lies in the establishment of clinical diagnosis. Imaging methods (ultrasonography, CT and MRI) have been shown to be helpful in the diagnosis; however, localized Castleman disease may be clinically and radiographically indistinguishable from other lymphoid and non-lymphoproliferative disorders.[4,9]Castleman disease is not usually included in the list of possible diagnosis, one of the reasons may be its low incidence. CT scan often shows a solid mass with well-def i ned margins. Dense enhancement immediately after the application of contrast medium is seen. Percutaneous fi ne-needle aspiration biopsy is often not diagnostic in Castleman disease,[5,21]which was true for our patient as well. The histological diagnosis of the disease is based on cell architecture, and therefore requires the study of the entire surgical specimen. Complete surgical resection is curative in unicentric forms of Castleman disease[24,25]with very good prognosis after complete resection.

Contributors:?F proposed the study. JB and ?Z wrote the fi rst draft. FA, KP and RR collected and analyzed the data. All authors contributed to the design and interpretation of the study. ?F is the guarantor.

Funding:The work was supported by Research Project MZO 00179906 from the Ministry of Health Care, Czech Republic.

Ethical approval:Not needed.

Competing interest:No benef i ts in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Received October 25, 2011

Accepted after revision July 27, 2012

AuthorAff i liations:Department of Surgery (?e?ka F, Ferko A, Jon B and ?ubrt Z), Fingerland Department of Pathology (Ka?parová P) and Second Department of Internal Medicine (Repák R), Faculty of Medicine and University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic; Department of Field Surgery, Military Health Science Faculty, Hradec Králové, Defence University Brno, T?ebe?ská 1575, 500 01 Hradec Králové, Czech Republic (?ubrt Z)

Filip ?e?ka, MD, PhD, Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic (Tel: 420-737-163931; Fax: 420-495-832026; Email: fi lip.cecka@seznam.cz)

? 2013, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(13)60053-3