Case
A 59-year-old African American man presents with a history of progressive jaundice and recent-onset depression. He is a former smoker. He has a family history of pancreatic cancer. His blood sugar is elevated. Computed tomography scan of the abdomen and pelvis reveals a 2.3-cm mass in the head of the pancreas. There is regional lymphadenopathy.
Therapeutics
Surgical resection is the only potentially curative option in the management of pancreatic cancer. Because the stage is typically advanced at presentation, surgery is only considered in a minority of cases. Approx imately 20% of patients will be operative candidates at the time of diagnosis.
Table Differential diagnosis of mass lesions in the pancreas
| Pathologic diagnosis | Tumor type |
| Pancreatic adenocarcinoma | Malignant |
| Pancreatic neuroendocrine | Malignant |
| tumor | |
| Acinar cell carcinoma | Malignant |
| Metastatic tumor to thepancreas | Malignant |
| Lymphoma | Variable malignant grade |
| Cystic lesion of the pancreas | Benign, premalignant, or malignant |
| Focal pancreatitis | Benign |
| Autoimmune pancreatitis | Benign |
Even with appropriate patient selection and complete surgical resection, only a subset of resected patients will achieve a cure. ERCP has a role in the palliation of obstructive jaundice. External beam radiation therapy with concomitant chemotherapy (5-fluorouracil, gemcitabine, paclitaxel) is primarily used for symptom palliation with modest improvements in mean survival.
Table Absolute and relative contraindications to surgical resection of pancreatic cancer. The range is represented from top (absolute) to bottom (relative) of the table
| Metastases to the liver, peritoneum, omentum, or any extra-abdominal site |
| Encasement of celiac axis, hepatic artery, or superior mesenteric artery |
| Involvement of splenoportal confluence |
| Involvement of bowel mesentery |
| Involvement of superior mesenteric vein or portal vein |
Case continued
The patient is not a candidate for resection due to involvement of the superior mesenteric artery (stage T4) and is referred to oncology. Oncology recommends chemoradiation therapy for palliation of symptoms. The patient undergoes chemoradiation therapy with initial improvement in his symptoms. His cancer progresses and he elects hospice care.
Case
A 76-year-old woman with congestive heart failure and hematuria undergoes a computed tomography scan to rule out nephrolithiasis. A 2-cm cystic lesion is noted in the tail of the pancreas. She denies any history of pancreatitis or heavy alcohol consumption. She denies abdominal pain or discomfort. There is mild dilatation of the main pancreatic duct.
Therapeutics
Because of the risk of malignancy, surgical resection of suspected malignant cystic neoplasms may be indicated. A dilated main pancreatic duct, mural nodules, size greater than 3 cm, dysplasia on a biopsy, and the presence of pancreatic symptoms are indications for resection. Small incidental pancreatic cysts may enlarge over a prolonged period, and morbidity or mortality due to these cysts is low; therefore, observation may be a safe management option in some cases. The decision to monitor high-risk patients with small (<2 cm) incidental cystic neoplasms should follow a discussion regarding the low risk of cancer (3.5%) but high risk of progression to malignancy (50%).
Table Features and characteristics of common cystic lesions of the pancreas. Other less common cystic lesions include cystic endocrine neoplasm, ductal adenocarcinoma with cystic degeneration, lymphoepithelial cyst, and acinar cell cystadenocarcinoma
| Cyst type | Pathology | Aspirate | Carcinoem bryonic antigen ng/mL | Amylase | Management | |
| Pseudocyst: no true epithelial lining, walls are of | Develops as a result of pancreatic | Thin, dark, opaque,non-mucinous, with
inflammatory cells |
Low | High | No malignant potential,resection or
endoscopic management indicated for |
|
| adjacent structures | nflammation and necrosis, | |||||
| Frequently associated with pain | communicates with the ductal system | |||||
| Look for gland atrophy, duct dilatation,calcification of the parenchyma, calculi in
pancreatic duct |
Contains high concentrations of amylase | |||||
| Lining is fibrous with granulation tissue | ||||||
| Lacks an epithelial lining | symptoms | |||||
| Mucinous cystadenoma: most common cysticneoplasm | Dense mesenchymal ovarian-like stroma | Viscous, clear, variablecellularity, positive for
mucin |
High>200 | Low | After resection,non-invasive MCN-no
recurrence |
|
| Lack communication with pancreatic duct | ||||||
| Typically occurs in middle-aged women | May have 1 or more macrocystic spacesined by mucous-secreting cells | |||||
| Typically solitary97% are distal (body and tail) | ||||||
| Peripheral eggshell calcification issuggestive of malignancy | ||||||
| May be malignant at time of diagnosis | ||||||
| Serous cystadenoma: 2nd most common cystictumor of the pancreas | Typically composed of multiple, small cystsined by glycogen-rich cuboidal
epithelium |
Less viscous, thin, clear,non-mucinous, may be
bloody |
Low<5 | Low | Resection is curative | |
| Middle-aged women | ||||||
| Typically solitary | Chromosomal alterations of gene for von | |||||
| Very LOW malignant potential | Hippel-Lindau locus 3p25 found inmajority | |||||
| Central scar highly suggestive but found in -20% | ||||||
| Intraductal papillary mucinous neoplasm (sidebranch or main duct) | Consists of dilated ductal segments,usually within the head of the pancreas,
ined by mucous-secreting cells |
Viscous, clear, with mucin | High(>1000 concerning
for malignancy) |
High | Resection (especially forpatients with nodules
or symptoms) |
|
| Patients may have multiple cysts | ||||||
| More common in men | Main duct Intraductal papillary mucinous neoplasms has greater malignantpotential | Serial imaging forhigh-risk patients
with low-risk features |
||||
| A dilated pancreatic duct implies a main duct | ||||||
| Intraductal papillary mucinous neoplasms | Mural nodules and a segmental or diffusedilatation of the pancreatic duct >15 mm
are worrisome for malignancy |
|||||
| Mucin extrusion from widely patent ampulla (fishmouth deformity) is pathognomonic | ||||||
| Side branch Intraductal papillary mucinous neoplasms is more common |
Most mucinous cystic neoplasms are located in the tail of the pancreas. The risk of progression can be weighed against the risk of postoperative pancreatic fistula (29%) and mortality (0.8%) with distal pancreatectomy. Surveillance can be performed with computed tomography, magnet resonance imaging (magnetic resonance imaging), or Endoanal ultrasound-FNA. Resection may be readdressed if imaging demonstrates a significant change in diameter or morphology.
Case continued
The patient is referred for Endoanal ultrasound with FNA. Endoanal ultrasound-FNA reveals a 2-cm lesion with a mural nodule and mild main pancreatic ductal dilation. A distal pancreatectomy is performed, revealing Intraductal papillary mucinous neoplasms. The patient develops a postoperative pancreatic leak but recovers and is discharged home.
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