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Journal of Indian Association of Pediatric Surgeons
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LETTER TO THE EDITOR
Year : 2017  |  Volume : 22  |  Issue : 1  |  Page : 64-65
 

Pancreatoblastoma masquerading as a retroperitoneal germ cell tumor


Department of Pediatric Surgery, Kalawati Saran Children Hospital, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Date of Web Publication23-Nov-2016

Correspondence Address:
Muffazzal Rassiwala
Department of Pediatric Surgery, Kalawati Saran Children Hospital, Lady Hardinge Medical College and Associated Hospitals, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.194633

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How to cite this article:
Rassiwala M, Patel JN, Yadav PS, Jhanwar P. Pancreatoblastoma masquerading as a retroperitoneal germ cell tumor. J Indian Assoc Pediatr Surg 2017;22:64-5

How to cite this URL:
Rassiwala M, Patel JN, Yadav PS, Jhanwar P. Pancreatoblastoma masquerading as a retroperitoneal germ cell tumor. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2017 Jul 27];22:64-5. Available from: http://www.jiaps.com/text.asp?2017/22/1/64/194633


Sir,

We read with interest the article entitled, "Pancreatoblastoma masquerading as hepatoblastoma: A diagnostic dilemma." [1] The authors have reported a very challenging clinicoradiologic diagnostic problem. We report a similar case wherein a 7-month-old male infant with abdominal lump, low-grade fever, and slightly elevated serum alpha-fetoprotein (AFP >2000 ng/ml) was initially suspected to be a retroperitoneal germ cell tumor (GCT); however, review of radiology and histopathology revealed the tumor to be a pancreatoblastoma.

Ultrasound examination revealed a large mixed echogenic mass arising from the retroperitoneum and indistinguishable from pancreatic body and tail. The characteristic radiologic findings on computed tomography (CT) were a well-defined, heterogeneously enhancing retroperitoneal tumor with tumor thrombus in the splenoportal venous axis and multiple venous collaterals [Figure 1].
Figure 1: Contrast-enhanced computed tomography showing a well-defined heterogeneously enhancing retroperitoneal mass with tumor thrombus at porta hepatis

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Fine-needle aspiration cytology showed malignant cells of undifferentiated origin, possibly - sarcoma or carcinoma. Awaiting histopathological conformation by incisional biopsy, an initial diagnosis of a large retroperitoneal GCT was made and neoadjuvant chemotherapy initiated. There was no clinical response to chemotherapy and the patient developed gross ascites with anasarca. A review of the CT findings of thrombosis along the splenoportal axis with search of literature prompted a rethink of the diagnosis, keeping pancreatoblastoma as a more likely possibility. Characteristic immune histochemistry (positive for cytokeratin [CK], vimentin, CK 7, and AFP) confirmed the diagnosis of pancreatoblastoma. The patient responded well to cisplatin- and doxorubicin-based chemotherapy (PLADO) and a spleen-preserving distal pancreatectomy was performed after three cycles of neoadjuvant chemotherapy. Postoperatively, two more cycles of chemotherapy were given and the patient was followed up with serial AFP levels and ultrasound examination.

Our case highlights the fact that giving undue importance to the raised serum AFP levels may lead to the misdiagnosis. Drozynska et al. [2] also reported a case of pancreatoblastoma misdiagnosed as a GCT on the basis of the clinical and radiologic signs with raised serum AFP levels and emphasized the importance of tissue biopsy in making the correct diagnosis. In advanced pancreatic tumors, including cases of pediatric pancreatoblastoma, tumor invasion and thrombosis of the portal venous system have been reported and are characteristic findings which point to the diagnosis. [3],[4] In retrospect, the presence of thrombosis in the splenoportal venous axis along with the raised serum AFP levels and the CT findings of an upper abdominal, retroperitoneal mass should have avoided the initial misdiagnosis in our patient and pancreatoblastoma should be in differential diagnosis.

Acknowledgment

We would like to acknowledge Dr. Murtuza Rassiwala for his help in the preparation of this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Prabhu A, Bhagat M, Ramadwar M, Qureshi SS. Pancreatoblastoma masquerading as hepatoblastoma: A diagnostic dilemma. J Indian Assoc Pediatr Surg 2016;21:84-6.  Back to cited text no. 1
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2.
Drozynska E, Bien E, Polczynska K, Stefanowicz J, Zalewska-Szewczyk B, Izycka-Swieszewska E, et al. A need for cautious interpretation of elevated serum germ cell tumor markers in children. Review and own experiences. Biomark Med 2015;9:923-32.  Back to cited text no. 2
    
3.
Yonekura T, Kosumi T, Hokim M, Hirooka S, Kitayama H, Kubota A. Aggressive surgical and chemotherapeutic treatment of advanced pancreatoblastoma associated with tumor thrombus in portal vein. J Pediatr Surg 2006;41:596-8.  Back to cited text no. 3
    
4.
Zheng J, Zhang H, Sun Y, Sun B. CT-guided radiofrequency ablation following high-dose chemotherapy of a liver-metastasizing pancreatoblastoma with tumor thrombus in the portal vein. Pediatr Radiol 2013;43:1391-5.  Back to cited text no. 4
    


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