PMC5925002_01
CT scan performed at the third day of admission. (a) Axial CT image in the portal venous phase. Normal appearance of the orthotopic pancreas (white asterisks). A nonsignificant small amount of retroperitoneal fluid on the level of the pancreas tail (white curved arrows). Presence of a large amount of free intraperitoneal fluid (black curved arrows). (b-c) Coronal and axial CT image in the portal venous phase. Enhancing soft tissue mass (black asterisk) with surrounding mesenteric edema (white arrowhead). Suggestion of a central ductal structure (black arrow). (d) Coronal CT image in the early arterial phase shows a comparable enhancement of the orthotopic and heterotopic pancreas (resp., white and black asterisks).
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fig1
CT revealed a normal morphology and homogenous enhancement of the pancreas, with only a small amount of fluid located around the tail of the gland (Figure 1(a)). Also, the presence of a central ductal, tubular structure was suggested (Figures 1(b)-1(d)).
(a) Ultrasound image of the mesenteric soft tissue mass (black asterisks) with surrounding inflammatory changes (white arrowhead). (b) Coronal TRUFI image depicting the soft tissue mass with signal characteristics according to the orthotopic pancreas (white asterisk). Surrounding, edematous inflammatory changes (white arrowhead) and a possible central duct (black arrow). (c) EUS image of the hypoechoic mesenteric soft tissue mass, in the transversal plane measuring approximately 3 x 4 cm. (d). EUS image of an enlarged mesenteric lymph node, with a short axis of 9 mm, demonstrating no suspicious morphological features.
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Ultrasound depicted a nonspecific hypoechoic region in the mesentery with a central, lobulated, unsharp delineated, more hyperechoic soft tissue mass (Figure 2(a)). The coronal TRUFI revealed a mesenteric soft tissue mass with signal characteristics resembling the orthotopic pancreas, surrounding inflammatory changes, and a possible duct (Figure 2(b)); however, these findings were noncontributory for the diagnosis. EUS performed from the horizontal part of duodenum showed a hypoechogenic mass of 3 x 4 cm with indistinct delineation and poor vascularisation with adjacent enlarged lymph nodes and inflammatory changes (Figures 2(c) and 2(d)). The mass is evidently more hyperechoic than during the episode of inflammation (Figure 2(c)).
CT scan performed six weeks after admission. (a-b) Coronal and axial image in the arterial phase. (c-d) Axial images in the portal venous phase. Intra-abdominal free fluid is completely resolved. Heterotopic pancreas (black asterisks) in the mesentery with attenuation characteristics after intravenous contrast comparable to the orthotopic pancreas (white asterisks). Moreover, presence of a central duct is suggested (black arrow). There is an apparent decrease in inflammatory changes (white arrowheads) surrounding the heterotopic pancreas, though several adjacent mesenteric lymph nodes have increased in size (white arrows).
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The orthotopic pancreas was unremarkable (Figure 3).
EUS image of the hyperechoic mesenteric soft tissue mass (black asterisk) with a hypoechoic, ductal structure (black arrow).
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EUS was executed. EUS performed from the horizontal part of the duodenum depicted the pancreas-like mass with apparent ductal structures (Figure 4).
Fine-needle aspirate of the mesenteric soft tissue mass, MGG staining. (a) Overview, magnification 50x. Both groups of ductal cells (black arrow) and acinar cells (black arrowhead) are depicted in this image. (b) Magnification 200x, details of the cylindrical ductal cells. (c) Magnification 200x, details of the acinar pancreatic cells.
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Cytopathologic examination confirmed the hypothesis of heterotopic pancreas showing pancreatic epithelium with both acini and ducts (Figure 5).
(a) Intraoperative view on the proximal jejunum and its mesentery showing the heterotopic pancreas extending centrally. (b) Gross specimen of the segment resection after the jejunum is opened, demonstrating the heterotopic pancreas (white arrowheads) connected to the jejunum and the second manifestation of heterotopic pancreas in the serosa of the jejunum (black arrowhead).
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Treitz (Figure 6(a)). The resection included a second spot of presumed heterotopic pancreas at the antimesenteric side of the jejunum, several centimeters distally of the primary heterotopic pancreas (Figure 6(b)).