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Introducción. La neoplasia sólida pseudopapilar de páncreas, también conocida como tumor de Frantz, es una patología poco frecuente, que comprende menos del 3 % de los tumores pancreáticos, y la mayor incidencia se observa en mujeres jóvenes entre la segunda y tercera década de la vida. Su etiología es desconocida. El tratamiento de elección es la resección quirúrgica sin linfadenectomía cuando se encuentra bien localizado. Inclusive aún cuando hay evidencia de metástasis o invasión local, el manejo quirúrgico sigue siendo el tratamiento de elección. Caso clínico. Mujer de 24 años de edad, con masa abdominal palpable, dolorosa, de tres semanas de evolución. La tomografía computarizada mencionó como presunción diagnóstica un tumor de origen pancreático. En la laparotomía se encontró una masa dependiente del cuerpo del páncreas. Se realizó pancreatectomía distal radical con esplenectomía y omentectomía parcial en bloque. Resultados. Durante la cirugía no se presentaron complicaciones y hasta el sexto mes de seguimiento, la evolución fue adecuada y sin recidiva tumoral. Conclusiones. Ante la presencia de masa abdominal, con compromiso pancreático documentado por tomografía computarizada, se debe considerar el diagnóstico de neoplasia sólida pseudopapilar de páncreas, o tumor de Frantz. El tumor de Frantz es una entidad poco frecuente que generalmente se diagnostica de forma incidental o por síntomas inespecíficos en estadios avanzados. El diagnóstico y manejo de esta neoplasia representa un reto y la resección quirúrgica continúa siendo el tratamiento indicado.

Introduction. Solid pseudopapillary neoplasia of the pancreas, also known as Frantz tumor, is a rare pathology, comprising less than 3% of pancreatic tumors, and the highest incidence is observed in young women between the second and third decades of life. Its etiology is unknown. The treatment of choice is surgical resection without lymphadenectomy when it is well located. Even when there is evidence of metastasis or local invasion, surgical management remains the treatment of choice. Clinical case. A 24-year-old woman presented with a palpable, painful abdominal mass of three weeks' duration. The computed tomography mentioned a tumor of pancreatic origin as a presumptive diagnosis. At laparotomy, a mass dependent on the body of the pancreas was found. Radical distal pancreatectomy with splenectomy and en bloc partial omentectomy was performed. Results. During the surgery there were no complications and until the sixth month of follow-up, the evolution was adequate and without tumor recurrence. Conclusions. In the presence of an abdominal mass, with pancreatic involvement documented by computed tomography, the diagnosis of solid pseudopapillary neoplasia of the pancreas, or Frantz tumor, should be considered, which must be treated surgically. Frantz tumor is a rare entity that is generally diagnosed incidentally or due to nonspecific symptoms in advanced stages. The diagnosis and management of this neoplasia represents a challenge and surgical resection continues to be the indicated treatment.

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Introducción. El esplenúnculo se ha descrito con una incidencia global del 10 al 30 %. Puede ser una entidad de origen congénito o adquirida, frecuentemente está asociada a trauma abdominal o antecedente de esplenectomía por diversas causas. Caso clínico. Mujer en edad media, con antecedente de trauma abdominal y esplenectomía por ruptura traumática, quien 30 años después presenta un cuadro de dolor abdominal. Los estudios imagenológicos identificaron una masa sólida intrapancreática. Resultados. Fue llevada a pancreatectomía distal. Los hallazgos histológicos e inmunohistoquímicos confirmaron que la masa pancreática correspondía a un esplenúnculo intrapancreático adquirido, asociado al evento traumático previo. Conclusión. Los esplenúnculos suelen constituir un "incidentaloma". Los estudios imagenológicos se encuentran limitados, pues la tomografía computarizada, la resonancia nuclear magnética y la ultrasonografía presentan características imagenológicas similares con los tumores pancreáticos hipervascularizados, por lo que se debe practicar el estudio histopatológico durante su valoración. Esta entidad se debe incluir dentro de los diagnósticos diferenciales, con mayor énfasis en aquellos pacientes con historia de trauma abdominal y esplenectomía asociada, un escenario en el que esta lesión puede simular una neoplasia sólida del páncreas, con características malignas.

Introduction. Splenunculus has been described with an overall incidence of 10 to 30%. It can be an entity of congenital or acquired origin, it is frequently associated with abdominal trauma or a history of splenectomy for various reasons. Clinical case. Middle-aged woman, with a history of abdominal trauma and splenectomy due to traumatic rupture, who 30 years later presents with abdominal pain. Imaging studies identified a solid intrapancreatic mass. Results. She was taken to OR for distal pancreatectomy. The histological and immunohistochemical findings confirmed that the pancreatic mass corresponded to an acquired intrapancreatic splenunculus, associated with the previous traumatic event. Conclusion. Splenuncles usually constitute an "incidentaloma". Imaging studies are limited, since computed tomography, magnetic resonance imaging, and ultrasonography present similar imaging characteristics with hypervascularized pancreatic tumors, so histopathological study must be included during their evaluation. This entity should be included in the differential diagnoses, with greater emphasis on those patients with a history of abdominal trauma and associated splenectomy, a scenario in which this lesion can simulate a solid neoplasm of the pancreas, with malignant characteristics.

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Introducción: La duodenopancreatectomía cefálica o cirugía de Whipple ha sido el procedimiento quirúrgico electivo como tratamiento de las patologías neoplásicas de páncreas, duodeno y vías biliares. A pesar de los avances en técnicas quirúrgicas continúa siendo un gran desafío el manejo multidisciplinario. Materiales y Métodos: Estudio analítico, retrospectivo, de corte transversal, de pacientes postoperados de duodenopancreatectomía cefálica mayores de 18 años, ingresados a una unidad de Cuidados Intensivos, de enero de 2022 a julio de 2023. Variables evaluadas: características sociodemográficas (edad, sexo); comorbilidades asociadas; variables de interés en UCI (SOFA, APACHE, días de internación en UTI, días de internación hospitalaria, requerimiento de Intubación orotraqueal IOT, días de IOT, requerimiento de vasopresores), desenlace en UTI; variables de interés quirúrgicas: duración de la cirugía, complicaciones quirúrgicas. Resultados: Se incluyeron 24 pacientes. La media de edad: 66 años (mín:35; Máx: 85; RIC: 59-77); 14 (58%) sexo femenino. Comorbilidades más frecuentes: Hipertensión arterial 17 (71%), Diabetes Mellitus 26 (25%), Cardiopatía 3. SOFA al ingreso media de 4; (mín:1; Máx: 11; DS:3); APACHE al ingreso: media de 15; (mín:6; Máx: 24; DS: 4); media de internación en UTI fue de 6 días (mín:1; Máx: 68; DS: 14). Se constataron 5 (21%) óbitos. Factores asociados a la mortalidad el uso de vasopresores (p=0,013), insuficiencia renal aguda (p=0,009), infección del sitio quirúrgico (p=0,023), y una media de SOFA estimada en 9 (p=0,0012). Conclusión: Es fundamental el manejo multidisciplinario de pacientes sometidos a cirugía de Whipple a fin de optimizar los resultados, previniendo la aparición de complicaciones, y disminuyendo de esta forma la morbimortalidad de los mismos.

Introduction: Cephalic pancreaticoduodenectomy or Whipple surgery has been the elective surgical procedure as a treatment for neoplastic pathologies of the pancreas, duodenum and bile ducts. Despite advances in surgical techniques, multidisciplinary management continues to be a great challenge. Materials and Methods: Analytical, retrospective, cross-sectional study of postoperative cephalic duodenal-pancreatectomy patients over 18 years of age, admitted to an Intensive Care unit, from January 2022 to July 2023. Variables evaluated: sociodemographic characteristics (age, sex); associated comorbidities; variables of interest in the ICU (SOFA, APACHE, days of ICU admission, days of hospitalization, requirement for orotracheal intubation IOT, days of IOT, requirement for vasopressors), outcome in ICU; surgical variables of interest: duration of surgery, surgical complications. Results: 24 patients were included. Median age: 66 years (min: 35; Max: 85; IQR: 59-77); 14 (58%) female. Most frequent comorbidities: High blood pressure 17 (71%), Diabetes Mellitus 26 (25%), Heart disease 3. SOFA at admission average of 4; (min:1; Max: 11; DS:3); APACHE upon admission: average of 15; (min:6; Max: 24; DS: 4); Mean ICU stay was 6 days (min: 1; Max: 68; SD: 14). There were 5 (21%) deaths. Factors associated with mortality were the use of vasopressors (p=0.013), acute renal failure (p=0.009), surgical site infection (p=0.023), and a mean estimated SOFA of 9 (p=0.0012). Conclusion: Multidisciplinary management of patients undergoing Whipple surgery is essential in order to optimize results, preventing the appearance of complications, and thus reducing their morbidity and mortality.

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El linfangioma quístico del páncreas (LQP), es un tumor extremadamente raro y representa solo el 1% de los linfangiomas abdominales. El objetivo de este manuscrito fue reportar un caso de LQP intervenido quirúrgicamente; y revisar la evidencia existente respecto de sus características morfológicas, terapéuticas y pronósticas. Mujer de 67 años, con LQP operada en Clínica RedSalud Mayor Temuco en septiembre de 2023. Se verificó un tumor sólido-quístico de 16 cm de diámetro mayor, adherido al páncreas a nivel del cuerpo de la glándula, de 867 gramos de peso, con líquido amarillento en su interior; la que fue extirpada completamente. Después del estudio histológico, se realizaron tinciones inmunohistoquímicas complementarias para CD31, D2-40 y calretina. La paciente tuvo un curso postoperatorio sin incidentes, siendo dado de alta al tercer día postoperatorio. En el control alejado, se encontraba en buenas condiciones generales. El LQP es un tumor muy poco frecuente. Las características clínicas e imágenes de este tipo de lesiones son inespecíficas. Debe considerarse en el diagnóstico diferencial de las lesiones quísticas pancreáticas. La resección quirúrgica completa con márgenes libres es el tratamiento de elección; y el pronóstico del LQP es favorable si se reseca por completo.

SUMMARY: Pancreas cystic lymphangioma (PCL) are extremely rare, accounting for only 1% of abdominal lymphangiomas. The aim of this study was to report a rare case of PCL, who underwent surgery; and review the existing evidence regarding its morphological, therapeutic and prognostic characteristics. 67-year-woman patient with PCL who underwent surgery at Clínica RedSalud Mayor Temuco in September 2023. In this case, a solid-cystic tumor with a major diameter of 16 cm was identified, adhering to the pancreas at the level of the body of the gland, weighing 867 grams and containing yellowish fluid in its interior. The tumor was completely excised. Subsequent to histological examination, additional immunohistochemical staining was performed for CD31, D2-40, and calretinin. The patient experienced an uneventful postoperative course and was discharged on the third postoperative day. During the follow-up, the patient remains in good general condition. LQP is a very rare tumor. Clinical features and images of this type of lesions are nonspecific. It should be considered in the differential diagnosis of pancreatic cystic lesions. Complete surgical resection with free margins is the treatment of choice; and the prognosis of LQP is favorable if it is completely resected.

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Introducción. La fístula pancreática postoperatoria es una de las complicaciones más importantes en la cirugía hepatobiliopancreática. Su diagnóstico se hace mediante la presencia de un nivel de amilasa en el líquido de drenaje al menos tres veces por encima del valor de la amilasa en suero a partir del tercer día postoperatorio. El objetivo de este estudio fue caracterizar los pacientes con fístula pancreática postoperatoria en nuestra institución, evaluando la importancia de la detección temprana y el establecimiento de un manejo oportuno. Métodos. Estudio descriptivo, retrospectivo, que incluyó los pacientes sometidos a pancreatoduodenectomía, con diagnóstico de fístula pancreática postoperatoria como complicación de cirugía hepatobiliopancreática, en el Hospital Internacional de Colombia, en Piedecuesta, entre enero del 2017 y diciembre de 2020. Se excluyeron los pacientes con otro tipo procedimiento quirúrgico y aquellos que decidieron no participar en el estudio. Resultados. Se evaluaron 69 pacientes, con un predominio del sexo femenino (n=38; 55,1 %) y mediana de la edad de 57 años. El 33,3 % (n=24) de los pacientes intervenidos desarrollaron fístula pancreática postoperatoria, siendo el 23,2 % fuga bioquímica, grado B 8,7 % y grado C 2,9 %, para quienes se indicaron manejo expectante, control ecográfico y reintervención, respectivamente. Fallecieron 5 pacientes (7,2 %). Conclusiones. La fístula pancreáticapostoperatoria es una complicación para tener en cuenta en todos los pacientes sometidos a pancreatoduodenectomía. Existen estrategias que pueden permitir disminuir la incidencia de esta complicación, con el fin de mejorar el desenlace, el pronóstico y la morbilidad posquirúrgica.

Introduction. Postoperative pancreatic fistula is one of the most important complications in hepatobiliopancreatic surgery. Its diagnosis is made by the presence of an amylase level in the drainage fluid at least three times above the serum amylase value from the third postoperative day. The objective of this study was to characterize patients with postoperative pancreatic fistula at our institution, evaluating the importance of early detection and to establish a timely management. Methods. Descriptive, retrospective study that included patients who underwent pancreatoduodenectomy with a diagnosis of postoperative pancreatic fistula as a complication of hepatobiliopancreatic surgery at the Hospital Internacional Colombia, between January 2017 and December 2020. Patients with another type of procedure performed by this specialty and those who did not decide to participate in the study were excluded. Results. A total of 69 patients were included, the median age was 57 years with a predominance of females (n=38; 55.1%). 33.3% (n=24) of the operated patients developed postoperative pancreatic fistula, with 23.2% having a biochemical leak, grade B in 8.7% and grade C in 2.9%, for whom expectant management, ultrasound control and reintervention were indicated, respectively. Five patients died (7.2%). Conclusions. Pancreatic fistula is a complication to take into account in all patients undergoing pancreatoduodenectomy. There are strategies that can reduce the incidence of this complication and thus improve not only the outcome but also the prognosis and postoperative morbidity.

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ABSTRACT In its 20th anniversary, laparoscopic pancreatoduodenectomy, while feasible and safe in the hands of experienced surgeons, has not seen the anticipated popularity observed in other digestive surgery procedures. The primary hurdle remains the absence of a clear advantage over traditional open surgery, paired with the procedures complexity and a consequent steep learning curve. In regions with limited pancreatic surgery services, conducting this procedure without adequate training can have serious repercussions. Given the advent of robotic platforms and the anticipation of prospective and randomized studies on this new technology, it is imperative to engage in comprehensive discussions, endorsed by surgical societies, on the value, application, and implementation strategies for various minimally invasive pancreatoduodenectomy techniques. Such dialogue is crucial for advancing the field and ensuring optimal patient outcomes.

RESUMO No ano em que completa 20 anos, a Pancreatoduodenectomia Laparoscópica, embora factível e segura em mãos experientes, não obteve uma esperada popularização como aquela observada em vários outros procedimentos no campo da cirurgia digestiva. A ausência de uma clara vantagem sobre a cirurgia aberta associada a complexidade do procedimento com consequente difícil e demorada curvas de aprendizado são os principais obstáculos. Em nosso país onde se dispõe de poucos serviços de cirurgia pancreática as consequências da prática desse procedimento sem um adequado treinamento pode trazer sérios prejuizos. Torna-se imperativo, agora com difusão das plataformas robóticas e enquanto se aguarda os estudos prospectivos e randomizados com essa nova tecnologia, que uma ampla discussão seja feita com chancela das sociedades de cirurgia sobre o valor, a aplicação e a forma de implantação das diversas técnicas de pancreatoduodenectomia minimamente invasivas.

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ABSTRACT Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive and lethal form of cancer with limited prognostic accuracy using traditional factors. This has led to the exploration of innovative prognostic models, including convolutional neural networks (CNNs), in PDAC. CNNs, a type of artificial intelligence algorithm, have shown promise in various medical applications, including image analysis and pattern recognition. Their ability to extract complex features from medical images makes them suitable for improving prognostication in PDAC. However, implementing CNNs in clinical practice poses challenges, such as data availability and interpretability. Future research should focus on multi-center studies, integrating multiple data modalities, and combining CNN outputs with biomarker panels. Collaborative efforts and patient autonomy should be considered to ensure the ethical implementation of CNN-based prognostic models. Further validation and optimisation of CNN-based models are necessary to enhance their reliability and clinical utility in PDAC prognostication.

RESUMO Contexto O adenocarcinoma ductal pancreático (ACDP) é uma forma de câncer altamente agressiva e letal com precisão prognóstica limitada usando fatores tradicionais. Isso levou à exploração de modelos prognósticos inovadores, incluindo redes neurais convolucionais (CNNs), no ACDP. As CNNs, um tipo de algoritmo de inteligência artificial, mostraram promessa em várias aplicações médicas, incluindo análise de imagem e reconhecimento de padrões. Sua capacidade de extrair características complexas de imagens médicas as torna adequadas para melhorar o prognóstico no ACDP. No entanto, a implementação de CNNs na prática clínica apresenta desafios, como a disponibilidade de dados e a interpretabilidade. Pesquisas futuras devem se concentrar em estudos multicêntricos, integrando múltiplas modalidades de dados e combinando saídas de CNN com painéis de biomarcadores. Esforços colaborativos e autonomia do paciente devem ser considerados para garantir a implementação ética de modelos prognósticos baseados em CNN. Mais validação e otimização de modelos baseados em CNN são necessárias para aumentar sua confiabilidade e utilidade clínica na prognostico do ACDP.

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Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

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Abdominal pain is severe in the vast majority of patients with pancreatic cancer. In some cases, chronic use of analgesics markedly reduces quality of life due to side effects. Endoscopic ultrasound-guided celiac plexus neurolysis is a procedure that controls cancerassociated pain in this population and consists of injecting a neurolytic agent around or within the celiac plexus. In this report, we present three cases with different technical approaches for celiac plexus neurolysis.

El cáncer de páncreas se puede presentar con dolor abdominal intenso, siendo necesario el uso de analgésicos a largo plazo en muchos de los pacientes. Sin embargo, estos medicamentos pueden tener efectos adversos que finalmente reducen la calidad de vida de los pacientes. La neurólisis del plexo celíaco guiada por ecoendoscopia es un procedimiento que controla el dolor asociado a este tipo de neoplasia y consiste en inyectar un agente neurolítico en o alrededor del plexo celíaco. Presentamos tres casos en los cuales se realizan diferentes técnicas de abordaje terapéutico.

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El carcinoma de células renales (CCR) a nivel mundial presenta una incidencia de 431.288 casos anuales, causando 179.368 muertes en 2020. Sin embargo, a pesar de su incidencia, el desarrollo de metástasis pancreática (MP) de un RCC es un hecho inusual. El objetivo de este manuscrito fue reportar el caso de una paciente con una MP metacrónica de un CCR. Se trata de una paciente de 56 años, sexo femenino, nefrectomizada derecha hace 132 meses por un CCR, en adyuvancia con inmunoterapia. En un control imagenológico de rutina, se le pesquisó una lesión de aspecto tumoral en el cuerpo y cola del páncreas. Se intervino quirúrgicamente, realizándose una pancreatectomía córporo-caudal con preservación esplénica. Evolucionó de forma satisfactoria, sin complicaciones, siendo dada de alta al 4º día de su cirugía. El informe del estudio de la pieza operatoria con estudio inmunohistoquímico concluyó que se trataba de una MP de CCR. La paciente se encuentra en buenas condiciones generales y reinició quimioterapia con anticuerpos monoclonales. El seguimiento frecuente y prolongado de pacientes con antecedentes de CCR, facilita un diagnóstico y tratamiento oportuno de MP facilitando el mejor pronóstico de los pacientes, con tasas más altas de supervivencia.

SUMMARY: Renal cell carcinoma (RCC) worldwide has an incidence of 431,288 cases per year, causing 179,368 deaths in 2020. However, despite its incidence, the development of pancreatic metastasis (MP) from RCC is unusual. The aim of this manuscript was to report the case of a patient with a PM of a RCC. This is a 56-year-old female patient, underwent right nephrectomy 132 months earlier for RCC. While she was in adjuvant immunotherapy, in a routine imaging control, it was found a tumor lesion in the body and the tail of the pancreas. So, she underwent surgery, performing a corpora-caudal pancreatectomy with splenic preservation. Postoperative evolution was correct, without complications, and she was discharged on the 4th day after surgery. The report of the study of the surgical piece with an immunohistochemical study included, conclusive of PM of RCC. Currently, the patient is in good general condition and restarted chemotherapy with monoclonal antibodies. Frequent and prolonged follow-up of patients with a history of RCC facilitates timely diag- nosis and treatment of PM, facilitating the best prognosis for patients, with higher survival rates.

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Introducción. Un biomarcador se define como una alteración molecular presente en el desarrollo de la patogénesis del cáncer, que puede ser utilizada para el diagnóstico temprano de la enfermedad. La medición del biomarcador se hace por medio de diversas técnicas, como bioquímica, inmunohistoquímica o biología molecular, en diferentes tipos de muestras, como tejido, sangre periférica y orina. El biomarcador ideal será aquel que sea válido y específico a la vez, que sea no invasivo, barato y fácilmente detectable. El uso de biomarcadores para la detección temprana del cáncer debe seguir un desarrollo ordenado y sistemático antes de introducirlos en la práctica clínica. Métodos. Se realizó una búsqueda exhaustiva en las bases de datos de PubMed y Embase, seleccionando los artículos pertinentes para revisarlos acorde a la temática específica de interés. Resultados. Se propone la sistematización del desarrollo de biomarcadores en cinco grandes fases, las cuales tienen la característica de ser ordenadas desde las evidencias más tempranas hasta las fases finales de su estudio. Conclusiones. El correcto desarrollo de biomarcadores hace posible la introducción de intervenciones terapéuticas en el ámbito de la prevención secundaria del cáncer.

Introduction. A biomarker can be defined as a molecular alteration present in the development of cancer pathogenesis which can be used for early diagnosis of the disease. The measurement of the biomarker can be carried out through various techniques such as biochemistry, immunohistochemistry, molecular biology, in different types of samples such as tissue, peripheral blood, and urine. The ideal biomarker will be one that is valid and specific while is non-invasive, cheap, and easily detectable. The use of biomarkers for the early detection of cancer must follow an orderly and systematic development before introducing them into clinical practice. Methods. An exhaustive search was performed in PubMed and Embase databases, selecting the relevant articles according to the specific topic of interest. Results. Systematization of the development of biomarkers in five large phases is proposed, which has the characteristic of being ordered from the earliest evidence to the final phases of their study. Conclusions. The correct development of biomarkers makes possible the introduction of therapeutic interventions in the field of secondary prevention of cancer.

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La ictericia colestásica se debe a la alteración de la secreción de bilirrubina conjugada; es una de las posibles causas la alteración del flujo biliar por obstrucción de la vía biliar extrahepática. El linfoma es la tercera neoplasia más frecuente en pediatría, mientras que los tumores pancreáticos son poco frecuentes y, en su mayoría, lesiones benignas. Las manifestaciones clínicas de los tumores de localización retroperitoneal son poco específicas y suelen ser tardías, por lo que la sospecha clínica debe ser alta. El objetivo del siguiente trabajo es presentar el caso de un niño de 7 años con síndrome colestásico en el que se halló un tumor en la cabeza del páncreas que comprimía la vía biliar extrahepática. El diagnóstico del tumor fue linfoma no Hodgkin (LNH). Se destaca la infrecuencia de este tumor en esta localización en la edad pediátrica

Cholestatic jaundice is due to an alteration in conjugated bilirubin secretion; a possible cause is an altered bile flow resulting from an obstruction of the extrahepatic bile duct. A lymphoma is the third most common neoplasm in pediatrics, while pancreatic tumors are rare and mostly benign. The clinical manifestations of retroperitoneal tumors are not very specific and are usually late, so a high level of clinical suspicion is required. The objective of this study is to describe the case of a 7-year-old boy with cholestatic syndrome with a tumor in the head of the pancreas compressing the extrahepatic bile duct. The tumor diagnosis was non-Hodgkin lymphoma (NHL). It is worth noting that the presence of a tumor in this location in pediatric age is uncommon

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Pancreatic cancer is a malignant neoplasm with a poor prognosis. When it manifests clinically with cold jaundice, general repercussion or dyspepsia, it usually corresponds to a locally advanced tumor. Enterorrhagia as a form of presentation of pancreatic cancer is extremely infrequent; it corresponds to a severe form with an ominous prognosis. We present the case of a 61-year-old man who attended emergency service for enterorrhagia associated with organic abdominal pain and general repercussions, to whom a diagnosis of pancreatic tail cancer was diagnosed. Colonoscopy revealed mucosal infiltration with intense edema, erythema, necrosis, and spontaneous bleeding at the level of the splenic exure of the colon. Histology conrmed colonic infiltration by pancreatic neoplasm. Computed tomography allowed staging in stage IV. Palliative surgical treatment was performed, with a survival of 3 months.

El cáncer de páncreas corresponde a una neoplasia maligna con pobre pronóstico. Cuando se manifiesta clínicamente con ictericia fría, repercusión general o dispepsia, habitualmente corresponde a un tumor localmente avanzado. La enterorragia como forma de presentación del cáncer de páncreas es extremadamente infrecuente, corresponde a una forma grave y de pronóstico ominoso. Se presenta el caso de un hombre de 61 años que consultó por enterorragia asociada a dolor abdominal de características orgánicas y repercusión general, en el que se realizó diagnóstico de cáncer de cola de páncreas. La colonoscopía evidenció a nivel del ángulo esplénico del colon, infiltración mucosa con intenso edema, eritema, necrosis y sangrado espontáneo. La histología confirmó la infiltración colónica por neoplasma de páncreas. La tomografía computarizada permitió su estadificación en estadio IV. Se realizó tratamiento quirúrgico paliativo, con una sobrevida de 3 meses.

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Resumo O adenocarcinoma ductal de pâncreas é uma das neoplasias malignas mais agressivas, com taxas de sobrevivência anuais inferiores a 20%. Os métodos axiais (tomografia computadorizada e ressonância magnética) têm papel fundamental no diagnóstico e estadiamento da doença, por fornecerem adequada resolução anatômica na avaliação de estruturas-chave, principalmente vasculares. O adenocarcinoma ductal de pâncreas é frequentemente descoberto em estágios avançados e sem viabilidade de ressecção cirúrgica, e nesse cenário o desenvolvimento de alternativas terapêuticas minimamente invasivas tem sido ainda mais importante para a mudança de sua história natural. A eletroporação irreversível, procedimento intervencionista que minimiza efeitos deletérios nos tecidos adjacentes, vem se destacando no tratamento de lesões tradicionalmente consideradas irressecáveis. Essa técnica, apesar de ganhar cada vez mais espaço no manejo terapêutico do adenocarcinoma ductal de pâncreas, ainda é pouco familiar aos radiologistas. Neste estudo, buscamos expor, de forma sucinta e didática, os fundamentos da técnica, as principais características de imagem e os critérios de elegibilidade que devem ser considerados para indicação da eletroporação irreversível nessa doença.

Abstract Pancreatic ductal adenocarcinoma is one of the most aggressive malignant neoplasms, with a one-year survival rate below 20%. Axial methods (computed tomography and magnetic resonance imaging) play a fundamental role in the diagnosis and staging of the disease, because they provide adequate anatomical resolution in the assessment of key structures, mainly vascular structures. Pancreatic ductal adenocarcinoma is most often discovered in advanced stages, when surgical resection is no longer feasible. In that scenario, minimally invasive treatment alternatives have been developed in attempts to change the natural history of the disease. Irreversible electroporation, an interventional procedure that minimizes deleterious effects on adjacent tissues, has proven useful for the treatment of tumors traditionally considered unresectable. Despite the growing acknowledgment of this technique as a tool for the management of pancreatic ductal adenocarcinoma, it is still relatively unknown among radiologists. In this study, we sought to provide an overview of the main characteristics and eligibility criteria that must be considered for the indication of irreversible electroporation in cases of pancreatic ductal adenocarcinoma.

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ABSTRACT Background Pancreatic cancer mortality is greater in countries with a high Human Development Index (HDI). This study analyzed pancreatic cancer mortality rates trends, and their correlation with HDI in Brazil over 40 years. Methods: Data on pancreatic cancer mortality in Brazil between 1979 and 2019 were obtained from the Mortality Information System (SIM). Age-standardized mortality rates (ASMR) and Annual Average Percent Change (AAPC) were calculated. Pearson's correlation test was applied to compare mortality rates and HDI for three periods: 1986-1995 was correlated with HDI of 1991, 1996-2005 with HDI of 2000, and 2006-2015 with HDI of 2010; and to the correlation of AAPC versus the percentage change in HDI from 1991 to 2010. Results: A total of 209,425 deaths from pancreatic cancer were reported in Brazil, with an annual increase of 1.5% in men and 1.9% in women. There was an upward trend for mortality in most Brazilian states, with the highest trends observed in the North and Northeast states. A positive correlation between pancreatic mortality and HDI was observed over the three decades (r>0.80, P<0.05) and also between AAPC and HDI improvement by sex (r=0.75 for men and r=0.78 for women, P<0.05). Conclusion There was an upward trend in pancreatic cancer mortality in Brazil for both sexes, but rates among women were higher. Mortality trends were higher in states with a higher percentage improvement in HDI, such as the North and Northeast states.

RESUMO Contexto A mortalidade por câncer de pâncreas é maior em países com alto Índice de Desenvolvimento Humano (IDH). Este estudo analisou as taxas e tendências de mortalidade por câncer de pâncreas e correlacionou-as com o IDH no Brasil no período de 40 anos. Métodos: Os dados sobre mortalidade por câncer de pâncreas no Brasil, entre 1979 e 2019, foram extraídos do Sistema de Informações sobre Mortalidade (SIM). As taxas de mortalidade padronizadas por idade e variação percentual média anual (AAPC) foram calculadas. O teste de correlação de Pearson foi aplicado para comparar as taxas de mortalidade e IDH em três períodos: 1986-1995 foi correlacionado com o IDH de 1991, 1996-2005 com IDH 2000 e 2006-2015 com IDH 2010; e a correlação da AAPC versus o percentual de variação do IDH de 1991 a 2010. Resultados: Foram notificados 209.425 óbitos por câncer de pâncreas no Brasil no período de 1979 a 2019, com aumento de 1,5% ao ano em homens e de 1,9% em mulheres. Houve tendência de aumento da mortalidade na maioria dos estados brasileiros, com maiores tendências nos estados das regiões Norte e Nordeste. Foi observada uma correlação positiva na mortalidade por câncer de pâncreas e o IDH ao longo de três décadas (r>0,80, P<0,05); também, entre o AAPC e o incremento do IHD entre 1991 e 2010 (r=0,75 para homens e r=0,78 para mulheres, P<0,05). Conclusão: Houve tendência crescente da mortalidade por câncer de pâncreas no Brasil, em ambos os sexos, porém maior entre as mulheres. As tendências de mortalidade foram maiores nos estados com maior percentual de incremento do IDH, como estados das regiões Norte e Nordeste.

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Introdução: Os tumores neuroendócrinos pancreáticos são considerados raros. Eles são classificados em funcionantes e não funcionantes. Objetivo: Definir e classificar tumores neuroendócrinos pancreáticos de acordo com sua avaliação histopatológica e imunoistoquímica, associado aos critérios diagnósticos. Método: Trata-se de revisão narrativa sobre publicações encontradas no PubMed, SciELO e Google Acadêmico. Resultados: Esses tumores podem ser bem ou pouco diferenciados e apresentam características microscópicas distintas. As células bem diferenciadas têm formato pequeno, núcleos uniformes redondos ou ovais, citoplasma finamente granular indicando forte capacidade secretória e mantêm a estrutura organoide. A presença de necrose tumoral, atividade mitótica aumentada e índice de Ki-67 elevado indicam alta probabilidade de neoplasia neuroendócrina. Cromogranina A e sinaptofisina favorecem o diagnóstico do bem diferenciado. Já a marcação positiva do BCL 10 em conjunto com a ausência de expressão da cromogranina A e da sinaptofisina mostram a precária diferenciação tumoral. A presença de marcação positiva para as expressões hormonais não define o tumor como funcionante. Conclusão: Houve aumento do diagnóstico de tumores neuroendócrinos pancreáticos com o uso de técnicas de imagem e a conscientização sobre a doença. A análise histopatológica com imunoistoquímica, especialmente quando há sintomas consumptivos, podem indicar o tipo do carcinoma e induzir ao mais adequado tratamento.

Introduction: Pancreatic neuroendocrine tumors are considered rare. They are classified into functioning and non-functioning. Objective: To define and classify pancreatic neuroendocrine tumors according to their histopathological and immunohistochemical evaluation, associated with diagnostic criteria. Method: This is a narrative review of publications found in PubMed, SciELO and Google Scholar. \Results: These tumors can be well or poorly differentiated and have distinct microscopic characteristics. Well-differentiated cells are small in shape, have uniform round or oval nuclei, finely granular cytoplasm indicating strong secretory capacity, and maintain the organoid structure. Presence of tumor necrosis, increased mitotic activity and high Ki-67 index indicate a high probability of neuroendocrine neoplasia. Chromogranin A and synaptophysin favor the diagnosis of well-differentiated. The positive staining of BCL 10 together with the absence of expression of chromogranin A and synaptophysin show poor tumor differentiation. The presence of positive staining for hormone expressions does not define the tumor as functioning. Conclusion: There was an increase in the diagnosis of pancreatic neuroendocrine tumors with the use of imaging techniques and awareness of the disease. Histopathological analysis with immunohistochemistry, especially when there are consuming symptoms, can indicate the type of carcinoma and lead to the most appropriate treatment.

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ABSTRACT BACKGROUND: Para-aortic lymph nodes involvement in pancreatic head cancer has been described as an independent adverse prognostic factor. To avoid futile pancreatic resection, we systematically perform para-aortic lymphadenectomy as a first step. AIMS: To describe our technique for para-aortic lymphadenectomy. METHODS: A 77-year-old female patient, with jaundice and resectable pancreatic head adenocarcinoma, underwent pancreaticoduodenectomy associated with infracolic lymphadenectomy. RESULTS: The infracolic anterior technique has two main advantages. It is faster and prevents the formation of postoperative adhesions, which can make subsequent surgical interventions more difficult. CONCLUSIONS: We recommend systematic para-aortic lymphadenectomy as the first step of pancreaticoduodenectomy for pancreatic head adenocarcinoma by this approach.

RESUMO RACIONAL: O envolvimento dos gânglios linfáticos para-aórticos no câncer da cabeça do pâncreas tem sido descrito como um fator prognóstico adverso independente. Para evitar a ressecção pancreática inútil, realizamos sistematicamente linfadenectomia para-aórtica. OBJETIVOS: Descrever a técnica de linfadenectomia para-aórtica. MÉTODOS: Paciente do sexo feminino, 77 anos, com quadro de icterícia e adenocarcinoma da cabeça do pâncreas ressecável, submetida à duodenopancreatectomia associada à linfadenectomia infracólica. RESULTADOS: Esta técnica anterior infracólica tem duas vantagens principais: é mais rápida e evita a formação de aderências pós-operatórias, o que pode dificultar as intervenções cirúrgicas subsequentes. CONCLUSÕES: Recomendamos a linfadenectomia para-aórtica sistemática como o primeiro passo da duodenopancreatectomia para o adenocarcinoma da cabeça do pâncreas por esta abordagem.

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ABSTRACT Introduction: pancreaticoduodenectomy is a complex surgical procedure that can result in high rates of complications and morbimortality. Due to its complexity, the establishment of referral centers has increased in recent decades. This study aims to evaluate the influence of the institutional volume of pancreaticoduodenectomy for periampullary cancer on short-term outcomes in the Brazilian public health system. Methods: this study used a population-based approach and investigated the number of pancreaticoduodenectomies performed by institutions within Brazil's public health system between 2008 and 2021. High-volume institutions were defined as those that performed more than two standard deviations above the mean number of procedures per year. Specifically, if a center performed eight or more pancreaticoduodenectomies annually, it was considered a high-volume institution. Results: in Brazil, 283 public hospitals performed pancreaticoduodenectomy for cancer between 2008 and 2021. Only ten hospitals performed at least eight pancreaticoduodenectomies per year, accounting for approximately 3.5% of the institutions. High-volume institutions had a significantly lower in-hospital mortality rate than low-volume institutions (8 vs. 17%). No significant differences between groups were observed for length of stay, hospitalizations using the ICU, and ICU length of stay. The linear regression model showed that the number of hospital admissions for pancreaticoduodenectomy and age were significantly associated with hospital mortality. Conclusion: institutional pancreaticoduodenectomy volume implies a lowering of in-hospital mortality. The findings of this nationwide study can affect how the public health system manages pancreaticoduodenectomy care.

RESUMO Introdução: a duodenopancreatectomia é um procedimento complexo com alta risco de complicações e morbimortalidade. Devido à sua complexidade, a constituição de centros de referência tem aumentado nas últimas décadas. Este estudo tem como objetivo avaliar a influência do volume institucional de duodenopancreatectomia para câncer periampular em resultados de curto prazo no sistema público de saúde brasileiro. Métodos: este estudo utilizou uma abordagem de base populacional e investigou o número de duodenopancreatectomia realizadas por instituições do sistema público de saúde do Brasil entre 2008 e 2021. Definimos instituições de alto volume como aquelas que realizaram mais de dois desvios padrão acima do número médio de procedimentos por ano. Especificamente, um centro seria considerado de alto volume se realizasse oito ou mais duodenopancreatectomias anualmente. Resultados: no Brasil, 283 hospitais públicos realizaram duodenopancreatectomia por câncer entre 2008-2021. Apenas dez hospitais realizaram pelo menos oito duodenopancreatectomias anualmente, correspondendo a aproximadamente 3,5% das instituições. As instituições de alto volume tiveram uma taxa de mortalidade intra-hospitalar significativamente menor do que as instituições de baixo volume (8 vs. 17%). Não foram observadas diferenças significativas entre os grupos quanto ao tempo de internação, internações na UTI e tempo de internação na UTI. O modelo de regressão linear mostrou que o número de internações para duodenopancreatectomia e a idade estiveram significativamente associados à mortalidade hospitalar. Conclusão: o volume institucional da duodenopancreatectomia implica em diminuição da mortalidade intra-hospitalar. Os achados deste estudo nacional podem afetar a forma como o sistema público de saúde gerencia os cuidados com a duodenopancreatectomia..

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ABSTRACT BACKGROUND: Pancreatic cystic lesions are a group of pancreatic neoplasms with different behavior and risk of malignancy. Imaging diagnosis and differentiation of these lesions remain a challenge. AIMS: The aim of this study was to evaluate the agreement between computed tomography and/or magnetic resonance imaging and post-operative pathologic diagnoses of Pancreatic cystic lesions in a University Hospital of São Paulo State. METHODS: A total of 39 patients with surgically diagnosed Pancreatic cystic lesions were enrolled, as a study cohort from 2009 to 2019. Preoperative radiological and final pathological diagnosis was correlated to measure computed tomography and/or magnetic resonance imaging diagnostic. Pancreatic adenocarcinoma, choledochal pancreatic cyst, mucinous cystadenoma, serous cystadenoma, intraductal papillary mucinous neoplasms, and pancreatic pseudocyst were classified as neoplastic cysts. RESULTS: It was noted that 27 patients (69.23%) had preoperative computed tomography and magnetic resonance imaging, 11 patients (28.20%) had preoperative computed tomography only, and 1 patient had preoperative magnetic resonance imaging only. The values for diagnoses made only with computed tomography (p=0.47) and from the combination of computed tomography+magnetic resonance imaging (p=0.50) did also point to moderate agreement with the anatomopathological findings. The values pointed to a fair agreement for the diagnosis of mucinous cystadenoma (p=0.3), moderate agreement for intraductal papillary mucinous neoplasms (p= 0.41), good agreement for serous cystadenoma (p=0.79), and excellent agreement for choledochal pancreatic cyst (p=1), pancreatic pseudocyst (p=0.84), and Frantz tumor (p=1) (p<0.05). CONCLUSIONS: The findings of computed tomography and/or magnetic resonance imaging have an equivalent diagnostic agreement with an anatomopathological diagnosis for differentiating benign from malignant Pancreatic cystic lesions and in suggesting a specific diagnosis. There is no statistical difference between the use of computed tomography alone and computed tomography+magnetic resonance imaging in the improvement of diagnostic accuracy.

RESUMO RACIONAL: Lesões císticas pancreáticas são um grupo de neoplasias pancreáticas com diferentes comportamentos e riscos de malignidade. O diagnóstico por imagem e a diferenciação dessas lesões constituem um desafio. OBJETIVOS: Avaliar a concordância entre o diagnóstico de imagem pré operatório obtido através da tomografia computadorizada e/ou da ressonância nuclear magnética e o diagnóstico anátomopatológico das lesões císticas pancreáticas, no Hospital de Base de São José do Rio Preto - SP. MÉTODOS: Trinta e nove pacientes com lesões císticas pancreáticas, comprovados cirurgicamente, foram incluídos para o estudo, de 2009 a 2019. O diagnóstico radiológico pré-operatório e o diagnóstico anatomopatológico final foram correlacionadas para medir a acurácia da tomografia computadorizada e/ou da ressonância nuclear magnética. O adenocarcinoma pancreático, o cisto pancreato-coledociano, o cistoadenoma mucinoso, o cistoadenoma seroso, a neoplasia mucinosa papilar intraductal, e o pseudocisto pancreático foram classificados como cistos neoplásicos. As informações foram comparadas e estatisticamente analisadas. RESULTADOS: Vinte e sete pacientes fizeram tomografia computadorizada e ressonância nuclear magnética pré-operatórios (69,23%), 11 pacientes fizeram apenas tomografia computadorizada (28,20%), e 1 paciente fez apenas ressonância nuclear magnética (2,57%). Os achados de tomografia computadorizada para diagnóstico (p=0,47) e para a combinação tomografia computadorizada+RM (p=0,50) mostraram moderada concordância com os achados anatomopatológicos. Houve leve concordância para o diagnóstico de cistoadenoma mucinoso (p=0,3), moderada concordância para intraductal papillary mucinous neoplasms (p=0,41), boa concordância para cistoadenoma seroso (p=0,79) e excelente concordância para pseudocisto pancreático (p=0,84), cisto pancreato-coledociano (p=1) e tumor de Frantz (p=1) (p<0,05). CONCLUSÕES: Os achados de imagem da tomografia computadorizada e/ou ressonância nuclear magnética apresentaram concordância diagnóstica com os exames anatomopatológicos na diferenciação de lesões císticas pancreáticas benignas e malignas, porém a diferença entre o uso apenas da tomografia computadorizada e tomografia computadorizada+ressonância nuclear magnética na melhora da acurácia diagnóstica não apresentou relevância estatística tal como a literatura.

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Abstract Von Hippel-Lindau (VHL) disease is a monogenic autosomal dominant disorder with germline mutations of the VHL anti-oncogene on the short arm of chromosome 3 (3p25-26). It affects 1:36,000-50,000 individuals, with a penetrance greater than 90% at 65 years of age. Although of variable onset and presentation, with pleiotropism even among members of the same family who share a specific mutation, VHL disease usually manifests initially in young adults. It predisposes to the development of benign and malignant tumors of the central nervous system (CNS) and visceral organs. The clinical diagnosis of VHL disease can be made in the following circumstances: a) in patients with a family history of the disease and at least one of the tumors characteristic of it (e.g., retinal or CNS hemangioblastomas, clear cell renal cell carcinoma, pancreatic neuroendocrine tumors, and endolymphatic sac tumors); b) in patients with two or more CNS hemangioblastomas; c) or in patients with a retinal or CNS hemangioblastoma plus at least one visceral tumor characteristic of the disease, excluding renal and epididymal cysts. Imaging plays an important role in the diagnosis and follow-up of patients with VHL disease. This pictorial essay presents characteristic images of abdominal manifestations of VHL disease-related tumors that all radiologists should be aware of.

Resumo A doença de von Hippel-Lindau (VHL) é uma desordem autossômica dominante monogênica com mutações na linha germinativa do antioncogene VHL, no braço curto do cromossomo três (3p25-26). Afeta 1:36.000-50.000 indivíduos, com penetrância superior a 90% aos 65 anos de idade. Embora tenha início e apresentação variáveis, com pleiotropismo mesmo entre membros da mesma família que partilham uma mutação específica, usualmente manifesta-se de início em adultos jovens e predispõe ao desenvolvimento de tumores benignos e malignos no sistema nervoso central (SNC) e órgãos viscerais. Clinicamente, o diagnóstico pode ser realizado em uma das seguintes circunstâncias: a) em pacientes com história familiar de doença de VHL e pelo menos um dos tumores característicos relacionados à síndrome (como hemangioblastomas retinianos ou do SNC, carcinoma de células renais de células claras, tumores neuroendócrinos pancreáticos e tumores do saco endolinfático); b) dois ou mais hemangioblastomas do SNC; c) um hemangioblastoma retiniano ou do SNC mais pelo menos um tumor característico visceral relacionado à síndrome, excluindo-se cistos renais e epididimários. Nesse contexto, a imagem ocupa importante papel no diagnóstico e acompanhamento desses pacientes. Este ensaio iconográfico apresenta imagens características de manifestações abdominais de tumores relacionados à doença de VHL que todos os radiologistas devem conhecer.