Imaging of pancreatic serous cystadenocarcinoma

Pancreatic serous cystadenocarcinoma diagnosed with liver metastasis at 7 years after the resection of the primary serous neoplastic lesion

Pancreatic serous neoplasms are rare tumors that are usually benign. However, histopathological differentiation between benign (serous cystadenoma) and malignant (serous cystadenocarcinoma) lesions is difficult. We present the case of a patient with pancreatic serous cystadenocarcinoma that was diagnosed with liver metastasis 7 years after the resection of the primary serous neoplastic lesion. A woman in her 60 s was diagnosed with pancreatic serous cystadenoma based on imaging and histopathological examination findings. The tumor was resected, and the patient was followed up every 6 months to monitor tumor progression. At 7 years after the resection of the primary lesion, liver tumors showing marked flare-like contrast enhancements were detected on arterial phase computed tomography findings and on dynamic magnetic resonance imaging findings acquired 60 s after the administration of a contrast agent. Laparoscopic segmental hepatectomy of S4 and S6 was performed to resect these tumors. Histopathological examination revealed that these tumors were metastatic and developed from the primary lesion. Therefore, a diagnosis of serous cystadenocarcinoma was confirmed. The flare-like contrast enhancement around the metastatic liver lesions on computed tomography and dynamic magnetic resonance images may be an indicator of serous cystadenocarcinoma with liver metastasis that could assist in diagnosis.

A long-term survivor of metachronous liver metastases of pancreatic serous cystic neoplasm associated with von Hippel-Lindau disease

BACKGROUND

Pancreatic serous cystic neoplasm (SCN) is an uncommon exocrine neoplasm, which is believed to be a benign entity. However, some of these neoplasms may occasionally attain metastatic ability. Von Hippel-Lindau disease (VHL) manifests a dominantly inherited systemic syndrome accompanied by several benign or malignant tumors, including cystic tumors, in various organs. We describe here a long-term survival case who underwent surgical resection for metachronous liver metastases of pancreatic SCN associated with VHL disease.

CASE PRESENTATION

A 35-year-old woman with VHL underwent total pancreatectomy and right nephrectomy for pancreatic SCN and renal cell carcinoma, respectively. At the 4th year follow-up examination after the resection, contrast-enhanced computed tomography (CT) and gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) showed arterially hyper-enhanced neoplastic lesions in the segment VI and VIII of the liver. Partial resections of the liver were performed 53 months after the initial surgery. At the 6th month follow-up examination from the second surgery, one and two tumors located in the liver segment III, and VIII, respectively, were detected by contrast-enhanced CT and Gd-EOB-DTPA-enhanced MRI. Anterior segmentectomy and partial resection of the segment III were performed 66 months after the initial surgery and 13 months after the second, respectively. The tumors were pathologically diagnosed as liver metastases of pancreatic SCN synonymous with serous cystadenocarcinoma. She remains disease-free without recurrence 6.5 years after the last operation.

CONCLUSIONS

This is the first report of a case of metastatic SCN associated with VHL. Surgical resection might confer a favorable prognosis in patients of pancreatic SCN with liver metastases.

A Novel Treatment for Metastatic Serous Cystadenocarcinoma Using a Microwave Ablation: Case Report and Review of the Literature

ABSTRACT

The incidence of pancreatic cystic neoplasms has grown because of increased detection. Among these lesions, serous cystadenoma was traditionally thought to be universally benign and indolent. However, there is an exceedingly rare malignant variant of serous cystadenoma known as serous cystadenocarcinoma (SCAC) that can exhibit local invasion into adjacent structures, hepatic implants, and metastatic spread to the abdominal viscera. Diagnosis of SCAC can be challenging as it is histologically identical to serous cystadenoma. To better understand this entity, a review of all published accounts of SCAC was performed in which tumor and patient factors were characterized. In addition, we present the case of a 49-year-old woman who was found to have a solitary hepatic metastasis due to SCAC, 11 years after a distal pancreatectomy for serous cystadenoma. She was successfully treated with percutaneous microwave ablation and has no evidence of recurrence 3 years later. This report details the first published account of percutaneous ablation in such a setting. Compared with hepatectomy, hepatic ablation may offer a less invasive but equally effective treatment option in well-selected patients.

A case of a malignant serous neoplasm of the pancreas with synchronous vascular invasion and metachronous metastases

Serous neoplasms (SNs) of the pancreas are usually considered benign tumors. However, they rarely manifest malignant behaviors. Here we present a case of malignant SN and review the literature of malignant SN. A 71-year-old woman presented to our hospital with a palpable abdominal mass. Imaging studies revealed a 7 cm mass with a cluster of microcysts having a honeycomb appearance in the head of the pancreas, which invaded the superior mesenteric vein (SMV). After being clinically diagnosed with SN, pancreaticoduodenectomy was performed with resection of limited SMV. Microscopically, the tumor was diagnosed as an SN concomitant with the tumor thrombus in the SMV. Four years after the surgery, two liver tumors and two peritoneal nodules were detected and three of them were surgically resected. All of those lesions had a honeycomb appearance in their cut surfaces and they were microscopically indistinguishable from the originally resected SN. A review of the literature identified 22 cases of malignant metastatic SNs published to date. Even though extremely rare, metachronous metastasis could occur in SNs of the pancreas. Local invasion indicated an increased likelihood of future metastasis. Thus, periodic surveillance should be considered for SNs after resection, especially when they have a local invasion.

[Malignant Pancreatic Serous Cystic Neoplasm: A Case of Local Recurrence and Liver Metastasis that Occurred During Follow-Up]

Serous cystic neoplasms of the pancreas are usually benign, with a low malignant potential. Herein, we report a case of malignant serous cystic neoplasm of the pancreas treated with subtotal pancreatectomy, which progressed to local recurrence and metachronous hepatic metastasis during the regular follow-up period.

Endoscopic Ultrasound Imaging for Diagnosing and Treating Pancreatic Cysts

Cystic pancreatic lesions are increasingly diagnosed owing to the abundant use of cross-sectional imaging. Given their malignant potential, true pancreatic cysts should be considered for resection or periodic follow-up. Cystic lesions of the pancreas (CLPs) require further evaluation and management. Therefore, it is important to establish a solid diagnosis at the time of detection. Endoscopic ultrasound examination is the imaging modality of choice. Fine needle aspiration provides fluid for cytologic, biochemical, and molecular assays to classify lesions and predict biological behavior. This review provides an overview of the diagnosis and management of various types of commonly encountered true CLPs.

Malignant pancreatic serous cystic neoplasms: systematic review with a new case

Background

This study analyzes the clinicopathologic and radiologic characteristics of malignant serous cystic neoplasm (SCN) of the pancreas through systematic review and an institutional case report.

Methods

A comprehensive literature search was performed in the MEDLINE database to identify studies on malignant SCNs of the pancreas that had detailed clinicopathologic and radiologic information. A computerized systematic search of our institutional database was also performed to identify cases of malignant SCN for addition to the systematic review. Using the final included cases, we analyzed the clinicopathologic and radiologic features of malignant SCNs of the pancreas.

Results

A review of 136 candidate articles identified 26 studies with 26 cases that had detailed clinical information. Our institutional data search added one case. The systematic review of the 27 cases revealed that primary tumors (mean diameter 10.2 ± 4.0 cm) mainly involved the body and tail of the pancreas (n = 16) and frequently invaded adjacent organs (n = 19). Distant metastases occurred in 14 patients (synchronous, n = 5; metachronous, n = 8; both, n = 1), most commonly in the liver (n = 13). Imaging features of malignant SCNs of the pancreas were identical to the benign counterpart, except local invasion or distant metastases. The prognosis was excellent in that 17 were alive at the time of writing with a median follow-up period of 2 years.

Conclusions

The malignant potential of SCNs of the pancreas should be considered in the diagnosis and management of patients with pancreatic SCNs.

Serous Neoplasms of the Pancreas: A Clinicopathologic Analysis of 193 Cases and Literature Review With New Insights on Macrocystic and Solid Variants and Critical Reappraisal of So-called "Serous Cystadenocarcinoma"

The literature on "variants" and "malignant" counterparts of pancreatic serous cystic neoplasms (SCNs) is highly conflicted. Clinicopathologic characteristics of 193 SCNs were investigated, along with a critical literature review. For the macrocystic (oligocystic) variant, in this largest series, a demographic profile in contrast to current literature was elucidated, with 21% frequency, predominance in female individuals (4:1), body/tail location (1.7×), younger age of patients (mean age, 50 y), and frequent radiologic misdiagnosis as other megacystic neoplasms. Solid SCNs were rare (n=4, 2%) and often misinterpreted radiologically as neuroendocrine tumors. Available fine-needle aspiration in 11 cases was diagnostic in only 1. Radiologic impression was "malignancy" in 5%. Associated secondary tumors were detected in 13% of resections, mostly neuroendocrine. Secondary "infiltration" (direct adhesion/penetration) of spleen, stomach, colon, and/or adjacent nodes was seen in 6 (3%) fairly large SCNs (mean, 11 cm) with no distant metastasis. Three SCNs recurred locally, but completeness of original resection could not be verified. Our only hepatic SCN lacked a concurrent pancreatic tumor. Literature appraisal revealed that there are virtually no deaths that are directly attributable to dissemination/malignant behavior of SCNs, and most cases reported as "malignant" in fact would no longer fulfill the more recent World Health Organization criteria but instead would represent either (1) local adhesion/persistence of tumor, (2) cases with no histologic verification of malignancy, or (3) liver SCNs with benevolent behavior (likely representing multifocality, rather than true metastasis, especially considering there was no fatality related to this and no reported metastases to other remote sites). In conclusion, in contrast to the literature, the clinicopathologic characteristics of solid and macrocystic SCN variants are similar to their microcystic counterpart, although their radiologic diagnosis is challenging. Recurrence/secondary invasion of neighboring organs occurs rarely in larger SCNs but seems innocuous. An SCN should not be classified as "malignant" unless there is clear-cut evidence of histologic malignancy or documented distant metastasis.

Synchronous resection of pancreatic serous cystadenocarcinoma and liver metastasis: First reported case and review of literature

Cystic neoplasms account for approximately 10-20% of all pancreatic cysts and 1% of pancreatic cancers. Serous cystadenomas are considered benign tumors with almost no malignant potential, and thus the management is typically only observation with serial imaging. According to the current World Health Organization classification, cases with distant metastases are defined as serous cystadenocarcinomas. To date, only 17 such cases with concomitant synchronous or metachronous liver metastasis have been described in the literature, and eight of these reports described treatment of secondary liver lesions. This report describes the first case of synchronous resection of pancreatic serous cystadenocarcinoma and liver metastasis in a 56-year-old female patient. The patient is currently well after 30 months of follow-up with no tumor recurrence or new metastatic liver nodules based on magnetic resonance imaging.

Solid variant type of serous cystadenocarcinoma of the pancreas: a case report and review of the literature

Serous cystic neoplasms (SCN) of the pancreas are typically honeycombed microcystic masses, which are believed to be benign entity. This report describes a case of a 69-year-old man with a rare solid type of serous cystadenocarcinoma of the pancreas with liver metastases. A 6-cm well enhanced pancreatic tumor and multiple liver nodules were depicted with contrast medium on computed tomography scan. Distal pancreatectomy was performed at first operation. The cut surface of the tumor was solid and glossy appearance. Second operation of liver resection for all metastatic nodules was performed 27 months after the initial operation. The tumor cells in both the pancreas and the liver had cytoplasmic periodic acid-Schiff positive granules, which were completely digested by diastase. Eleven cases of serous cystadenocarcinoma of the pancreas have been reported in the literature. To our knowledge, this is the first case of a solid type serous cystadenocarcinoma.

Histological percutaneous diagnosis of stage IV microcystic serous cystadenocarcinoma of the pancreas

Malignant serous cystic neoplasms (SCN) of the pancreas are exceptionally rare, and only a few cases have been reported. As a result, SCN have been unanimously classified as benign tumours. Contrary to this conviction, in 1989, George et al published the very first case of a patient found to have a malignant pancreatic SCN. Up to the time of the submission of this paper, 27 cases of serous cystoadenocarcinomas have been published. In all the previously published cases of malignant SCN, the correct diagnosis was made postoperatively or at the time of autopsy. The authors present a case of a 68-year-old patient who was incidentally found to have a large liver mass on transthoracic echocardiogram ordered for suspected coronary artery insufficiency. Subsequent investigations revealed an additional large mass in the pancreas and percutaneous biopsies of both lesions revealed histological features consistent with malignant SCN metastasised to the left hepatic lobe.