Cystadenoma of the pancreas

CYSTADENOMA CLINTON

S. HERRMAN,

OF THE PANCREAS M.D.

Philadelphia,

T

AND NATHAN

ASBELL, M.D.

Pennsylvania

her genera1 heaIth had always been good. There were no urinary symptoms or Ioss of weight.. There was no history of trauma or of any para-

RUE cysts of the pancreas, whiIe rare enough to stimuIate our enthusiasm for accurate diagnosis and to

FIG I. Case I. Fiat pIate demonstrating calcified pancreatic cystadenoma.

arouse our interest in the most proficient manner of treatment, are more common than a perusal of the Iiterature wouId Iead one to believe. True cystadenomas, springing from the tai1 of the pancreas, were diagnosed preoperativeIy in both cases reported herein. Both cystadenomas gave surprisingly Iittle discomfort or symptoms and both were amenabIe to compIete extirpation.

FIG. 2. Case I. Photograph of specimen removed from patient. sitic infection. PhysicaI examination

CASE REPORTS

CASEI. L. D’A., Case No. 168047, fifty-four years of age, was admitted to the Jewish HospitaI on October 21, 1940, compIaining of pain in the epigastrium. For severa months preceding admission she had a “ feeIing of fuIIness” in the upper left quadrant of the abdomen. She had not vomited. Her bowel habits were reguIar; Juk

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was essentially negative except for the presence of a smooth, rounded mass the size of an orange in the upper left quadrant of the abdomen. The mass was not mobile from side-to-side but moved up and down with respiration. The fasting blood sugar ranged from 90 to 130 mg. per IOO cc. The bIood urea nitrogen was 13.3 mg. per IOO cc. BIood amyIase caIcuIation was not done. The flat pIate x-ray (Fig. I) showed a Iarge caIcified cyst. The preoperative diagnosis was cyst at the tai1 of the pancreas. Operation was performed on October 22, An upper Ieft 1940, under spinaI anesthesia. rectus incision was made. The tumor mass was most prominent between the stomach and

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FIG. 3 FIG. 4 FIG. 3. Case II. X-ray showing typicat pressure deformity of the stomach. FIG. 4. Case II. X-ray showing dispIacement of the stomach upward and the transverse colon downward.

transverse colon. AccordingIy, the gastric colic omentum was opened in an avascuIar area, the coIon being mobilized downward and the cyst exposed. Extirpation was decided upon as the method of choice and was accomplished by sharp dissection un tiI a pIane of cIeavage was obtained. It was easy to enucIeate the cyst by bIunt dissection with the finger down to its rather broad base in the tai1 of the pancreas. A smaI1 piece of the pancreas was excised with the cyst. (Fig. 2.) The wound in the pancreas was closed with interrupted sutures of Iinen thread. The rent in the mesocoIon was cIosed and the abdomen was cIosed without drainage. The patient made an uneventfu1 recovery and was discharged from the hospita1 on the eleventh postoperative day. FoIIow-up information was obtained from her family physician who reported her we11 and symptom-free one, three and five years after operation. The specimen consisted of a portion of pan1% cm. in Iength and a pancreas measuring creatic cyst measuring 855 cm. in diameter. The surface was irreguIar and hard in consistency. On cross section it consisted of a uniIocuIar cyst the Iining of which was thin and caIcified and fiIIed with amorphous, chocoIate material. Section of tissue showed a Iarge number of acini and pancreatic tissue lined by

cuboida1 cells arranged in cIuster formation. The nuclei resuIted on a basement membrane. There was pronounced hyperpIasia of the isIands of Langerhans. There was a numerica increase in the number of isIands as we11 as an increase in the size of individua1 islands. There was no evidence of malignancy. The diagnosis was cystadenoma of the pancreas. CASE II. M. W., Case No. 4263, thirty-six years of age, was referred to our service at St. Joseph’s HospitaI on December 13, 1946, compIaining of cramp-Iike pains and a sense of fuIIness in the upper Ieft quadrant of the abdomen. For the past year she had had pains after eating. There was no history of vomiting or change of bowe1 habits and no urinary symptoms. She had Iost IO pounds in the past year but this may have been by purposeful dieting. She had two chiIdren. Menstruation was reguIar. There was no history of abdomina1 trauma and physica examination was essentiaIIy negative except for the abdomina1 portion. Filling the entire upper left quadrant was a Iarge, smooth, rounded mass, the size of a basketbaI1. The spIeen couId not be paIpated separately. The mass was fixed; it couId not be moved from side-to-side and did not move with respiration. Vagina1 examination was negative. X-ray studies before admission to the hospital showed the presence

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FIG. 5 FIG. 5. Case II. Photograph showing specimen of the cyst with spleen attached Frti. 6. The same as Figure 5 showing the cyst opened.

of a tumor between the stomach and coIon. (Figs. 3 and 4.) On admission the patient’s blood count was within normal Emits, bIood sugar 123 mg. per IOO cc. and bIood urea 9.6 mg. per I00 cc. The Iaboratory reported a blood amyIase of 1,600 units. (The figure is so high that we question the accuracy of this determination.) Operation was performed on December 18, 1946, under fractional spina anesthesia. The abdomen was opened by an upper Ieft rectus incision. An enormous cyst, springing from the pancreas, was between the stomach and transverse colon. For compIete extirpation more room was needed than couId be obtained through the gastrocoIic omentum. Consequently, an indirect approach was made by turning the transverse coIon and great omenturn upward and opening the transverse mesocolon in an avascular area, with due regard for the middle coIic artery. With great difhcuIty, a plane of cIeavage was found after careful separation of the adhesions. Once the correct plane of cleavage was established it was easy to enucleate the cyst by bIunt dissection with a finger and occasiona sharp knife dissection. The splenic artery and vein were so incorporated in the cyst waI1 that we decided to remove the spleen with the cyst. Apparently the spIeen had not been functioning properly for some time due to pressure on its vesseIs. This is assumed because we noted and carefully left four accessory spIeens about the size of large cherries. Hemostatis was troublesome. Oozing from the cyst bed was controlled by

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FIG. 6 and portion of the pancreas.

gelofoam gauze. The rent in the mesocolon was cIosed around a smaI1, soft rubber drain. Convalescence was entirely uneventfu1. The patient was out of bed the following day and Ieft the hospita1 on the tenth postoperative day. Four months after operation her family physician reported that she was entirely we11 and symptom-free except for hepatitis with jaundice which occurred two months after operation and Iasted two weeks. This we attribute to the plasma or bIood which she received during the operation. The specimen (Figs. 3 and 6) consisted of the spIeen measuring 14 by 6 by 6 cm. with a Iarge cyst measuring 14 cm. in diameter intimateIy attached throughout its length. The cyst waI1 was 2 to 4 cm. thick. It was fibrous, muItiIocuIated and contained chocoIate-colored mucus-Iike material. Sections of the cyst wall showed characteristic epithelium with a singIe row of tall coIumnar cells with baseIy situated nucIei. In some regions the epithelium was papiIIary in formation but nowhere was there more than one Iayer of ceIIs seen. The underlying subepithelial tissue was fibrous. The diagnosis was benign muItiIocuIated papillary cystadenoma. Pascucci’

gives

the

incidence

of pancre-

atic cysts as 0.061 per cent. Brunschwig differentiates between true cysts and cystadenomas. more solid communication the cyst and

He in

states that consistency

the Iatter without

are free

between the 1ocuIations of that they rest in the pancre-

I IO

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FIG. 8 FIG. 7 FIG. 7. Intravenous urography showing normaI kidney outIine and Iarge cyst, Wing the Ieft hypochondrium. FIG. 8. X-ray, same case as Figure 7, showing typical gastric deformity and displacement of the intestine to the right.

atic bed rather than protrude from it by a pedicle. It seems to us that the fina decision must rest with the pathoIogist and must be based on his microscopy of the cyst waI1. We conceive that the consistency and intercommunication of the muItiIocuIar cyst is mereIy a progressive picture of pressure, hemorrhage and breakdown of its contents. Attempts at caIcification of true cysts of the pancreas have been made by aImost a11 authors. Pascucci, Thigpen, Kaufman, Johnson,2 Pinkhan and others each has his own differentiation. It is of IittIe moment except to separate the so-caIIed pseudocysts which are not cysts at a11 but collections of oId inflammatory processes. True cysts which constitute a distinct cIinica1 entity are either neopIastic in origin or retention cysts. A congenita1 cyst, for example, couId be of either variety but shouId not be considered as a separate entity. To be unnecessarily precise regarding their classification is unproductive and fooIish.

Judd, Mattson and Mahorner3 and many others have Iaid stress by diagram and description on the Iocation of the cysts describing them as between the stomach and the coIon, beneath the liver, beneath the coIon, etc. We contend this is as antiquated as a discussion of the coverings of a hernia. It is obvious that a cyst in its growth and development takes the Iine of Ieast resistance. It is unimportant where it becomes most superficia1. In its remova access to it wiI1 be obtained in the most convenient, safe approach that affords the most ease of manipuIation. SYMPTOMS

Symptoms produced by pancreatic cysts are symptoms of pressure. No signs or symptoms are pecuIiar to the Iesions. Waiter and CIeveIand4 state that 95 per cent of their patients had pain. Most writers mention such symptoms as cachectic state, Ioss of appetite and weight 10s~. These resuIt from pressure on the stomach. In Iike manner, constipation resuIts from American

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pressure on the coIon. GIycosuria and steatorrhea, depending on pancreatic deficiency, are aIways aIIuded to at this time. Their presence wouId indicate either destruction of a goodIy amount of the pancreas or interference with its function. In the two cases reported herein both patients had onIy one prominent symptom in the presence of major Iesions, nameIy, a “sense of fuIIness ” in the upper abdomen. PhysicaI examination reveaIed an obvious mass in the upper Ieft quadrant. The differentia1 diagnosis must be contemplated for maIignant tumors, aneurysms, retroperitonea1 growths, gaIIbIadder disorders with distention and, most particuIarIy, renal cysts or neoplasms and spIenomegaIies. X-ray examinations shouId incIude compIete gastrointestina1 study including barium enemas and intravenous ur0graphy.j Figure 7 shows an intravenous urography study with a norma kidney outline overIapped by, but differentiated from, the cyst. It is unbeIievabIe how Iarge a growth may be symptom-free. Figures 7 and 8 show the x-ray findings in M. L., Case No. 282, sixty-five years of age, whom we saw in consuItation in January, 1947, at St. Joseph’s HospitaI. He had a cystic mass the size and shape of a footbaI1 which extended from the ribs to the umbilicus on the Ieft side of the abdomen. From physica examination and x-ray findings we were convinced that he had a Iarge pancreatic cyst but the patient feIt so we11 that both he and his physician refused operation. It is surprising how IittIe has been added to our store of knowIedge concerning pancreatic cysts in the past twenty years. Moynihana wrote a masterfu1 chapter on pancreatic cysts, and Brunschwig7 wrote an equaIIy enIightening monograph. However, excmding the advances in surgica1 technic, practicaIIy nothing has been added in the intervening sixteen years. TREATMENT

Once the abdomen is opened and Iesion is identified, three procedures

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avaiIabIe: interna drainage, marsupiaIization or extirpation. No one wiI1 deny that the theoretic method of choice is excision. InternaI drainage,s-I2 whiIe ingenious, is not physioIogic and at times has proved compIeteIy unsatisfactory. MarsupiaIization with obIiteration of the sac by packing has been reported as good in the Iiterature. Judd and others report exceIIent resuIts. We have had no experience with this procedure but have observed severa cases in the hands of our coIIeagues, with unhappy resuIts. Brunschwig, in speaking of the indications for excision, states that the tumor must not be of excessive size, shouId be fairIy mobiIe and free of numerous and dense adhesions. We chaIIenge this dictum because had we folIowed it, neither patient wouId have been considered for excision. With a carefu1, deIiberate, anatomic approach, anticipating essentia1 structures and vesseIs and guarding against their injury, a pIane of cIeavage shouId be sought. Once this is estabIished a cyst which seems to have insurmountabIe obstacles to its removal can be sheIIed out with ease. An attempt shouId be made to remove the Iesion in every case. No harm wiII be done if due care is taken. If remova is impossibIe, one of the Iess advantageous methods can be used to terminate the operation. The absorbabIe hemostatic gauze was most heIpfu1 to us and its use shouId be borne in mind. We beIieve that in deaIing with this condition most of us are onIy “occasiona operators ” and hesitate to report on our meager experience. This causes true pancreatic cysts to appear to be Iess common than is actuaIIy the case. In Iike manner, onIy the more favorabIe resuIts from the Iarger and better clinics appear in the Iiterature. CONCLUSIONS I. True pancreatic cysts, whiIe rare, are more common than the literature indicates. 2. Too much emphasis has been placed on impractica1 classifications.

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3. Cases are presented to show. the simphcity of diagnosis with roentgenoIogic aid. 4. In the Iight of improved surgica1 technic and anesthesia a pIea is made for remova of the cyst rather than exteriorization or interna drainage. REFERENCES PASCUCCI, L. M. Pancreatic cysts and Iithiasis. Am. J. Roentgenol., 52: 80-87, rg44. 2. JOHNSON, THOMAS A. and LEE, WALTER E. Pancreatic cysts. S. Clin. Nortb America, 22: r6771692, 1942. 3. JUDD, E. STARR, MATTSON, H. and MAHORNER, H. R. Pancreatic cysts. Arch. Surg., 22: 838-849, I.

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4. WALTERS, W. and CLEVELAND, W. H. Surgical Iesions of the pancreas. Arch. Surg., 42: 819-838, 1941.

5. ORMOND, J. K., WADSWORTH, G. H., and MORLEY, H. V. Pancreatic lesions confusine uroloaical diagnosis. J. Ural., 48: 650, 1943. 6. MOYNIHAN, BERKELEY. AbdominaI Operations. PhiladeInhia. 1026. W. B. Saunders Co. 7. BRUNSCHWIG, ALEXANDER. Surgery of Pancreatic Tumors. St. Louis, 1942. C. V. Mosby Co. 8. CHESTERMAN,J. T. Treatment of pancreatic cysts. Brit. J. Surg., 30: 234-235, 1943. 9. BELOFF, J. S. Cvstadenoma of pancreas: caSe successfulIy treated by surgica1 extirpation. J. Mt. Sinai Hosp., 12: 817-820, ,945. IO. RABINOVITCH,J. and PINES, B. Cysts of pancreas. Arch. Surg., 45: 727-746, 1942. I I. EWING. J. NeopIastic Diseases. PhiladeIphia, 1940. W. B. Saunders Co. 12. JONES, E. S. Pancreatic cysts, with report of two unusual cases. J. Indiana M. A., 37: 175-179, r 944.

PAXTON and Payne studied the records of over 300 patients with acute pancreatitis and found that the patients operated upon had a mortaIity of about 45 per cent, whereas it was Iess than haIf as high for the patients treated medicaIIy. If the diagnosis is definite, I am sure the average surgeon aIso prefers conservative treatment. The authors stress the importance of bIood amyIase and urinary diastase tests and recommend that both be done (Richard A. Leonardo, M.D.) simuItaneousIy in questionable cases.

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