PICTURES IN DIGESTIVE PATHOLOGY

 

Giant symptomatic pancreatic cyst mimicking a malignant tumor

 

 

Lucas Souto-Nacif^1,2, Joana Ferrer-Fábrega¹, Rocío García-Pérez¹ and Juan Carlos García-Valdecasas¹

¹Department of Hepato-Bilio-Pancreatic Surgery and Transplantation. Institut de Malalties Digestives i Metabòliques (ICMDiM). Hospital Clínic. Barcelona, Spain.
²Liver and Gastrointestinal Transplant Division. Department of Gastroenterology. University of São Paulo School of Medicine. Brazil

 

 

Case report

A 52-year-old woman presented with weight loss, asthenia and epigastralgia. Computed tomography (CT) showed a 10 cm polycystic tumor in the pancreatic head, with Wirsung duct dilatation (17 mm), ample contact of the tumor with the superior mesenteric vein, involvement of the portal vein, gastroduodenal artery and compression of the duodenum (Fig. 1). The serum levels of CA19.9 and CEA were normal. Endoscopic ultrasound (EUS) revealed a large solid-cystic lesion occupying the pancreatic head (Fig. 2). The Wirsung duct was tortuous, with a 2 cm of dilation at the pancreatic body. Lesion fine-needle aspiration biopsy revealed cystic content with occasional epithelial cells and no atypia, with CEA levels of 47.9 ng/mL. A total pancreatectomy with portal reconstruction and splenectomy was performed. The pathological findings revealed a microcystic serous cystadenoma (Fig. 3).

 

 

 

 

Discussion

Differential diagnosis includes mucinous cystic neoplasms, neuroendocrine tumors, lymphangiomas, acinar cell cystadenocarcinomas, and serous cystadenocarcinomas (1). In clinical practice, cystic fluid analysis should be interpreted in combination with CT/magnetic resonance imaging and EUS to help in the diagnosis of unclear cases (2,3). Histologically, serous cystic neoplasms appear as epithelial cells connected by occluding junctions and belt desmosomes and have a central scar. Immunohistochemically, they are positive for cytokeratins 7, 8, 18, and 19. They can also be positive for CA19-9 and B72.3, being negative for CEA (3). The presence of symptoms and/or the inability to definitively exclude a premalignant or malignant tumor are considered as indications for surgical resection (3). Locally aggressive behavior tumors, with surrounding vessels or peripancreatic lymph nodes, were described in 5.1% of resected serous cystic neoplasms. Large tumor size and tumor location in the head of the pancreas were considered as independent risk factors for this aggressive behavior and to justify surgical resection (3). Finally, we recommend that cystic tumors with inconclusive clinical and imaging features should be radically treated.

 

Acknowledgments

The authors wish to thank all physicians who have helped to improve this publication: Josep Fuster and Santiago Sánchez (Hepato-Bilio-Pancreatic Surgery), María Ángeles García Criado (Radiology), Àngels Ginès (Endoscopic Ultrasound), Olga Balagué (Pathology), and Josep Maria Badía (Surgery, Hospital General de Granollers).

 

References

1. Hashimoto M, Watanabe G, Matsuda M, et al. Serous cystic neoplasm of the pancreas-indications for surgery. Hepatogastroenterology 2006;53:950-2.         [ Links ]

2. Thosani N, Thosani S, Qiao W, et al. Role of EUS-FNA-based cytology in the diagnosis of mucinous pancreatic cystic lesions: A systematic review and meta-analysis. Dig Dis Sci 2010;55:2756-66. DOI: 10.1007/s10620-010-1361-8.         [ Links ]

3. Del Chiaro M, Verbeke C, Salvia R, et al. European Study Group on Cystic Tumours of the Pancreas. European experts consensus statement on cystic tumors of the pancreas. Dig Liver Dis 2013;45:703-11. DOI: 10.1016/j.dld.2013.01.010.         [ Links ]