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Cystadenoma of the Pancreas
GASTROENTEROLOGY 67:155-158, 1974 Copyright© 1974 by The Williams & Wilkins Co.
Vol. 67, No. 1 Print ed in U.S.A.
CYSTADENOMA OF THE PANCREAS Report of a case and its arteriographic diagnosis L. CHEUNG, M.D., N. MATOLO, M.D., AND J. GARY MAXWELL, M.D. Departm ent of Surgery, University of Utah Medical Center, Salt Lake City, Utah
A patient with cystadenoma of the pancreas is reported. The gross appearance of this neoplastic cyst at first laparotomy led to the diagnosis of pseudocyst of the pancreas which was treated by internal drainage through a cystogastrostomy. Postoperatively , the patient's condition did not improve. Subsequently, the arteriographic appearance of the vascular pattern of the tumor was helpful in differentiating cystadenoma from pseudocyst and carcinoma. Radical resection of this large cystic tumor was accomplished in the second operation by subtotal pancreatectomy , splenectomy, and wedge resection of the stomach. It is emphasized that cystadenoma and pseudocyst may be similar in gross appearance, cystadenoma exhibits characteristic arteriographic features, and total excision is the treatment of choice for this unusual condition. Cystic lesions of the pancreas are relatively uncommon. The majority of the cysts of the pancreas that receive surgical attention are pseudocysts of the pancreas. 1 Cystadenoma comprised less than 10% of pancreatic cystic disease. 1- 3 Differentiation of the two at laparotomy can be difficult since cystadenoma can resemble pseudocyst in gross appearance. The preferred surgical procedure for pseudocysts is internal drainage 4 • 5 through an anastomosis of the matured thick wall of the pseudocyst to a suitable adjacent hollow viscus, while the optimal surgical treatment for cystadenoma is total excision. l-a We have recently had the opportunity to reexplore surgically a case of cystadenoma of the pancreas which was first treated by cystogastrostomy as pseudocyst of the pancreas. Arteriography has been found helpful in this case in the differentiation of Received October 15, 1973. Accepted January 17, 1974. Address requests for reprints to: Dr. Laurence Y. Cheung, University Medical Center, Department of Surgery, 50 North Medical Drive, Salt Lake City, Utah 84132. 155
cystadenoma from carcinoma and pseudocyst of the pancreas. Only 2 other cases of cystadenoma have been reported to be demonstrated by arteriogram. 6 It is the purpose of this report to emphasize the guidelines in differentiation of this rare condition from pseudocyst of pancreas , and to describe the characteristic arteriagraphic findings of cystadenoma.
Case Report A 50-year-old white female was well until 2 months prior to admission when she noted an asymptomatic left upper quadrant abdominal mass. She denied any history of abdominal trauma or alcoholism. One month prior to admission at the University of Utah Medical Center, she was hospitalized in another hospital where exploratory laparotomy and pancreatic cystogastrostomy were performed with the diagnosis of pancreatic pseudocyst. Serum amylase was normal before and after surgery. Postoperatively, she developed anorexia, nausea, vomiting, 30-lb weight loss in 1 month , and abdominal pain. She was referred to University of Utah Medical Center for evaluation. On a dmission she was afebrile with an obvious palpable a bdominal mass in the left upper quadrant extending 5 em below the costal
FIG. 1. Upper gastroi ntestinal st udy s howing patent cyst ogastrostomy wit h barium filling the pa ncreatic
cyst.
FIG . 2. A, art er ial ph ase of selective celiac arteriogram. Solid arrow indi cates the tran sve rse pancreatic artery wh ich a ppears to give vasc ul ar suppl y to the tumor mass. Open arrows show th e m argin of this vasc ul a r tumor. B, venous phase of the sa me arter io gram show ing vasc ul a r blush outlinin g the tumor bed (open arroZL·s ) with multiple s mall av asc ul ar a reas within the tumor .
156
July 1974
157
CASE REPORTS
-{
· . $~t;~ .··,·''\
FIG.
2B
margin. There was mild tenderness without found. Wide resection of the cystic tumor was rebo und , guarding, or ri gidi ty. Laboratory st ud- accompl ished b y subtotal pancreatectom y, ies revealed hematocrit 29, hemoglobin 9.3 mg splenectomy, and wedge resection of the stomper 100 ml, white count 4,000 per cc, with nor- ach. Microscopic examination confirmed the mal differential count. Electrolytes, blood urea diagnosis of cystadenoma of the pancreas. Postnitrogen , serum creatinine, serum and urine operative course was complicated by a left amylase, and liver function tests were all within subphrenic abscess which was drained and the normal limit s except for seru m albumin of 1.9 g patient was discharged in good condition . per 100 ml and alkaline phosphatase of 140 U. Stool gua iac was 4 + positive. Gastroscopy reDiscussion vealed a patent posterior cystogast rostomy . Primary cystic neoplasms of the panUpper gastrointestinal series showed a cystogastrostomy with barium filling th e pancre at ic cyst creas are rare. There are less than 200 (fig. 1). Th e radiolucent filling defects were reported cases of cystadenoma in the literinterpreted as blood clot s or lobulated cyst. ature. Analysis of these collected series 1- 3 Sto mach was only s lightly displaced ant eriorly, indicated that the lesion is benign , slow but marked displacement of ligament of Treitz growing with tendency to arise in the body to the right was noted. Liver and spleen scans and tail of the pancreas, and most often were normal. Selective celiac arteriogram demonstrated a vasc ul a r blush outlining th e tumor found in middle-aged women. Cystbed with multiple small avasc ular areas within adenocarcinoma is even rarer than cystadenoma. The gross appearance of the two the center of this tumor (fig. 2). Surgery was performed on May 28. 1973, and lesions, the similarity in ana"tomical locaa cyst ic tumor, approximately 20 em in diame- tions , age, sex, and incidence, and the ter in the body and tail of the pancreas, was frequent finding of a djacent areas of benign
158
Vol. 67, No . !
CASE REPORTS
and malignant tissue within the same tumor, all suggest that cystadenocarcinoma may develop from preexisting cystadenoma. Malignant degeneration, however, is usually slow and metastases are delayed. Both cystadenoma and cystadenocarcinoma should be treated by total excision if technically possible. Gross appearance of neoplastic cysts may vary and are not easily differentiated from pseudocysts of the pancreas. As in a previously reported case of cystadenocarcinoma, at initial laparotomy, this case was treated by internal drainage through a cystogastrostomy based on the diagnosis of pancreatic pseudocyst. High recurrence rate has been reported in the literature when cystadenoma was treated by marsupialization and drainage. 2 There are usually no characteristic symptoms in patients with cystadenoma. Absence of pancreatitis and abdominal trauma in the history, and the lack oflocal reaction due to inflammation at operation should make surgeons suspicious of the diagnosis of cystic neoplasm. A frozen section of t he cystic wall may be helpful in making the diagnosi~. Barium studies of the gastrointestinal tract usually show displacement of viscera by the pancreatic mass, but cannot differentiate cystic neoplasm from carcinoma of the pancreas or pseudocyst of the pan-
creas. In contrast to pseudocyst of the pancreas, which usually shows displacement and stretching of the vessels by an avascular mass, marked vascularity of the pancreatic neoplastic cyst produces characteristic blush in the selective arteriogram. In the case reported, multiple small ayascular areas within the vascular pattern of the tumor illustrate the characteristic angiographic finding of neoplastic cyst. Carcinoma of the pancreas often shows encasement of the vessels, but not marked vascularity within the tumor itself. REFERENCES 1. Harbrecht PJ: Cystic disease of the pancreas. Am J Surg 124:607-616, 1972 2. Piper CE, ReMine WH, Prietley JT: Pancreatic cystadenomata. JAMA 180:648-652, 1962 3. Becker WF, Welsh RA, Pratt HS: Cystadenoma and cystadenocarcinoma of the pancreas. Ann Surg 161 :845- 863, 1965 4. Warren WD, March WH, Sandusky WR: An ap· praisal of surgical procedures for pancreatic pseu· docyst. Ann Surg 147:903-920, 1958 5. Mercadier M: Cystoduodenal anastomosis for ce· phalic cyst of the pancreas. Ann Surg 153:81- 93 , 1961 6. Bieber WP, Albo RJ : Cystoadenoma of the pancreas. Its arteriographic diagnosis. Radiology 8:776-778, 1963 7. Rask MP: Cystadenocarcinoma of the pancreas. Act Chir Scand 138:735-737, 1972
Vol. 67, No. 1 Print ed in U.S.A.
CYSTADENOMA OF THE PANCREAS Report of a case and its arteriographic diagnosis L. CHEUNG, M.D., N. MATOLO, M.D., AND J. GARY MAXWELL, M.D. Departm ent of Surgery, University of Utah Medical Center, Salt Lake City, Utah
A patient with cystadenoma of the pancreas is reported. The gross appearance of this neoplastic cyst at first laparotomy led to the diagnosis of pseudocyst of the pancreas which was treated by internal drainage through a cystogastrostomy. Postoperatively , the patient's condition did not improve. Subsequently, the arteriographic appearance of the vascular pattern of the tumor was helpful in differentiating cystadenoma from pseudocyst and carcinoma. Radical resection of this large cystic tumor was accomplished in the second operation by subtotal pancreatectomy , splenectomy, and wedge resection of the stomach. It is emphasized that cystadenoma and pseudocyst may be similar in gross appearance, cystadenoma exhibits characteristic arteriographic features, and total excision is the treatment of choice for this unusual condition. Cystic lesions of the pancreas are relatively uncommon. The majority of the cysts of the pancreas that receive surgical attention are pseudocysts of the pancreas. 1 Cystadenoma comprised less than 10% of pancreatic cystic disease. 1- 3 Differentiation of the two at laparotomy can be difficult since cystadenoma can resemble pseudocyst in gross appearance. The preferred surgical procedure for pseudocysts is internal drainage 4 • 5 through an anastomosis of the matured thick wall of the pseudocyst to a suitable adjacent hollow viscus, while the optimal surgical treatment for cystadenoma is total excision. l-a We have recently had the opportunity to reexplore surgically a case of cystadenoma of the pancreas which was first treated by cystogastrostomy as pseudocyst of the pancreas. Arteriography has been found helpful in this case in the differentiation of Received October 15, 1973. Accepted January 17, 1974. Address requests for reprints to: Dr. Laurence Y. Cheung, University Medical Center, Department of Surgery, 50 North Medical Drive, Salt Lake City, Utah 84132. 155
cystadenoma from carcinoma and pseudocyst of the pancreas. Only 2 other cases of cystadenoma have been reported to be demonstrated by arteriogram. 6 It is the purpose of this report to emphasize the guidelines in differentiation of this rare condition from pseudocyst of pancreas , and to describe the characteristic arteriagraphic findings of cystadenoma.
Case Report A 50-year-old white female was well until 2 months prior to admission when she noted an asymptomatic left upper quadrant abdominal mass. She denied any history of abdominal trauma or alcoholism. One month prior to admission at the University of Utah Medical Center, she was hospitalized in another hospital where exploratory laparotomy and pancreatic cystogastrostomy were performed with the diagnosis of pancreatic pseudocyst. Serum amylase was normal before and after surgery. Postoperatively, she developed anorexia, nausea, vomiting, 30-lb weight loss in 1 month , and abdominal pain. She was referred to University of Utah Medical Center for evaluation. On a dmission she was afebrile with an obvious palpable a bdominal mass in the left upper quadrant extending 5 em below the costal
FIG. 1. Upper gastroi ntestinal st udy s howing patent cyst ogastrostomy wit h barium filling the pa ncreatic
cyst.
FIG . 2. A, art er ial ph ase of selective celiac arteriogram. Solid arrow indi cates the tran sve rse pancreatic artery wh ich a ppears to give vasc ul ar suppl y to the tumor mass. Open arrows show th e m argin of this vasc ul a r tumor. B, venous phase of the sa me arter io gram show ing vasc ul a r blush outlinin g the tumor bed (open arroZL·s ) with multiple s mall av asc ul ar a reas within the tumor .
156
July 1974
157
CASE REPORTS
-{
· . $~t;~ .··,·''\
FIG.
2B
margin. There was mild tenderness without found. Wide resection of the cystic tumor was rebo und , guarding, or ri gidi ty. Laboratory st ud- accompl ished b y subtotal pancreatectom y, ies revealed hematocrit 29, hemoglobin 9.3 mg splenectomy, and wedge resection of the stomper 100 ml, white count 4,000 per cc, with nor- ach. Microscopic examination confirmed the mal differential count. Electrolytes, blood urea diagnosis of cystadenoma of the pancreas. Postnitrogen , serum creatinine, serum and urine operative course was complicated by a left amylase, and liver function tests were all within subphrenic abscess which was drained and the normal limit s except for seru m albumin of 1.9 g patient was discharged in good condition . per 100 ml and alkaline phosphatase of 140 U. Stool gua iac was 4 + positive. Gastroscopy reDiscussion vealed a patent posterior cystogast rostomy . Primary cystic neoplasms of the panUpper gastrointestinal series showed a cystogastrostomy with barium filling th e pancre at ic cyst creas are rare. There are less than 200 (fig. 1). Th e radiolucent filling defects were reported cases of cystadenoma in the literinterpreted as blood clot s or lobulated cyst. ature. Analysis of these collected series 1- 3 Sto mach was only s lightly displaced ant eriorly, indicated that the lesion is benign , slow but marked displacement of ligament of Treitz growing with tendency to arise in the body to the right was noted. Liver and spleen scans and tail of the pancreas, and most often were normal. Selective celiac arteriogram demonstrated a vasc ul a r blush outlining th e tumor found in middle-aged women. Cystbed with multiple small avasc ular areas within adenocarcinoma is even rarer than cystadenoma. The gross appearance of the two the center of this tumor (fig. 2). Surgery was performed on May 28. 1973, and lesions, the similarity in ana"tomical locaa cyst ic tumor, approximately 20 em in diame- tions , age, sex, and incidence, and the ter in the body and tail of the pancreas, was frequent finding of a djacent areas of benign
158
Vol. 67, No . !
CASE REPORTS
and malignant tissue within the same tumor, all suggest that cystadenocarcinoma may develop from preexisting cystadenoma. Malignant degeneration, however, is usually slow and metastases are delayed. Both cystadenoma and cystadenocarcinoma should be treated by total excision if technically possible. Gross appearance of neoplastic cysts may vary and are not easily differentiated from pseudocysts of the pancreas. As in a previously reported case of cystadenocarcinoma, at initial laparotomy, this case was treated by internal drainage through a cystogastrostomy based on the diagnosis of pancreatic pseudocyst. High recurrence rate has been reported in the literature when cystadenoma was treated by marsupialization and drainage. 2 There are usually no characteristic symptoms in patients with cystadenoma. Absence of pancreatitis and abdominal trauma in the history, and the lack oflocal reaction due to inflammation at operation should make surgeons suspicious of the diagnosis of cystic neoplasm. A frozen section of t he cystic wall may be helpful in making the diagnosi~. Barium studies of the gastrointestinal tract usually show displacement of viscera by the pancreatic mass, but cannot differentiate cystic neoplasm from carcinoma of the pancreas or pseudocyst of the pan-
creas. In contrast to pseudocyst of the pancreas, which usually shows displacement and stretching of the vessels by an avascular mass, marked vascularity of the pancreatic neoplastic cyst produces characteristic blush in the selective arteriogram. In the case reported, multiple small ayascular areas within the vascular pattern of the tumor illustrate the characteristic angiographic finding of neoplastic cyst. Carcinoma of the pancreas often shows encasement of the vessels, but not marked vascularity within the tumor itself. REFERENCES 1. Harbrecht PJ: Cystic disease of the pancreas. Am J Surg 124:607-616, 1972 2. Piper CE, ReMine WH, Prietley JT: Pancreatic cystadenomata. JAMA 180:648-652, 1962 3. Becker WF, Welsh RA, Pratt HS: Cystadenoma and cystadenocarcinoma of the pancreas. Ann Surg 161 :845- 863, 1965 4. Warren WD, March WH, Sandusky WR: An ap· praisal of surgical procedures for pancreatic pseu· docyst. Ann Surg 147:903-920, 1958 5. Mercadier M: Cystoduodenal anastomosis for ce· phalic cyst of the pancreas. Ann Surg 153:81- 93 , 1961 6. Bieber WP, Albo RJ : Cystoadenoma of the pancreas. Its arteriographic diagnosis. Radiology 8:776-778, 1963 7. Rask MP: Cystadenocarcinoma of the pancreas. Act Chir Scand 138:735-737, 1972