Imaging findings in a case of cystic neoplasm of pancreas: A case report

Introduction: The spectrum of cystic neoplasms of the pancreas encompasses a wide range from benign to malignant. Serous cystadenomas are benign cystic tumors of the pancreas. Case Report: A 54-year-old female presented with pain in epigastrium with a lump in mid upper abdomen. On imaging there was a large, lobulated, well defined, multicystic, heterogeneously enhancing mass arising from the body of pancreas which was subsequently excised and on histopathological examination was found to be a serous cystadenoma of pancreas. Conclusion: The aim of this case report is to highlight the characteristic radiological features in cystic neoplasms of the pancreas along with a review of the relevant literature. (This page in not part of the published article.) IJCRI – International Journal of Case Reports and Images, Vol. 5 No. 5, May 2014. ISSN – [0976-3198] IJCRI 2014;5(5):351–354. www.ijcasereportsandimages.com Gupta et al. 351 CASE REPORT OPEN ACCESS Imaging findings in a case of cystic neoplasm of pancreas: A case report Pooja Gupta, Devika Gupta, Kamlesh Kumar Singh, Satish Mendonca


IntrOductIOn
There are various cystic neoplasms of the pancreas which can be benign to malignant. The cystic masses of pancreas can be pseudocysts, mucinous cystic neoplasms, serous cystadenoma and intraductal papillary mucinous neoplasms. The most common cystic neoplasms are mucinous followed by the serous cystadenomas. With the recent advances in imaging techniques more cases of pancreatic cystic neoplasms are being identified. Herein, we have a case of a middle aged female who presented with pain and lump in the epigastrium and on subsequent evaluation was found to have a cystic neoplasm in the body of pancreas.

cAsE rEPOrt
A 54-year-old female was presented with pain in epigastric region of six months duration and nausea, anorexia, weight loss and lump in mid upper abdomen of two months duration.
On admission to the hospital, chest and abdominal X-rays were performed which were inconclusive. Routine laboratory studies including hematological and biochemical parameters were normal. Serum amylase was within normal limits. Following this an ultrasound of the abdomen was performed. Ultrasound showed a well-delineated, multi-loculated, cystic lesion of size 5.2x6.2x7.7 cm in the body of the pancreas. The cysts were all subcentimetric giving a honeycomb appearance to the lesion ( Figure 1). Subsequently, a barium meal study was done which showed a smooth extrinsic indentation on the lesser curvature of the stomach (Figure 2). Contrast-enhanced computed tomography scan showed a large, lobulated, well defined, lesion with multiple subcentimetric non enhancing hypodense cystic areas with enhancing hyperdense walls in the body of pancreas ( Figure 3). Multiple discrete foci of calcifications were seen within the lesion (Figure 4). Anteriorly the lesion was reaching till anterior abdominal wall, posteriorly it was abutting the splenic vein, superiorly it was abutting the segment IV of liver and inferiorly it was abutting lesser curvature of stomach. After complete investigations, patient was diagnosed as a case of cystic tumor of pancreas and she was operated upon with resection of the lesion. Histology of resected pancreatic tissue revealed multicystic lesion in the body of pancreas containing cysts less than 1 cm in size lined by small flat to cuboidal cells ( Figure 5). There was no architectural or     cytological atypia noted. Based on the imaging findings and further confirmation by histopathology a diagnosis of serous cystadenoma of pancreas was made.

dIscussIOn
Serous cystadenomas are benign tumors of the pancreas. There is strong female predominance with a sex ratio of 2:1. The most common presenting symptom is vague abdominal pain. A palpable epigastric mass is present in nearly two thirds of cases.
Serous cystadenomas constitute 25% of all cystic tumors of the pancreas the majority of which are found in females [1]. The most common site of serous cystadenomas is the head and tail of pancreas. In our case, the lesion was present in the body of the pancreas. They are seen almost exclusively after 35 years of age and 82% occurs after 60 years of age. The diagnosis of serous cystadenoma can be done by various imaging modalities such as ultrasound, computed tomography (CT) scan, and endoscopic ultrasound. On CT scan 30% of cases have a fibrous central scar with or without a characteristic stellate calcification which is considered pathognomic for serous cystadenoma [2]. On contrast-enhanced CT scan, there is enhancement of the septae [3]. Serous cystadenomas have three morphologic patterns: polycystic, honeycomb, and oligocystic [4]. In 70% of cases, serous polycystic adenomas consist of a collection of cysts (usually more than six) which range from a few millimeters up to 2 cm in size [5]. On non-contrast CT, they appear as hypodense, cystic masses that frequently show calcifications [6]. The honeycomb pattern, seen in approximately 20% of patients, is characterized by numerous subcentimeter cysts that cannot be individually distinguished by crosssectional imaging. Therefore, cysts having the honeycomb pattern are seen as well defined lesions with soft-tissue attenuation seen on CT [7]. Oligocystic have fewer larger cysts which are usually greater than 2 cm in diameter.
Differential diagnostic features that help in distinguishing serous from mucinous cystic tumors include older age group, and presence of multiple (>6) small cysts in case of serous cystadenoma as opposed to mucinous cystadenomas in which cysts are larger and fewer in number.
Patients with serous cystadenoma are thought to have an excellent long-term prognosis. Hence is important to differentiate serous cystadenoma from other cystic tumors.

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