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Presented by Jonathan Epstein, M.D. and prepared by Jospeh Kronz, M.D.
Case 4: Elderly man presented with vague abdominal pain.
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1. Question
Week 3: Case 4
This elderly man presented with vague abdominal pain. A CT scan revealed a large (10 cm) cystic mass in the tail of the pancreas. The lesion had a honeycomb appearance and a central stellate scar. A distal pancreatectomy was performed.
Correct
Answer: Serous cystadenoma with PanINs
Histology: The lesion is a classic serous cystadenoma. It is composed of innumerable small (1-3 mm) cysts lined by a cuboidal lining. The lining cells have a clear cytoplasm (from glycogen) and centrally placed round uniform nuclei. In addition to the serous cystadenoma, the adjacent pancreas is remarkable for pancreatic intraepithelial neoplasia (PanIN). The PanIN lesions involve the smaller pancreatic ducts and are composed of a papillary epithelium with mild to moderate atypia (PanIN-1 to PanIN-2).
Discussion: Serous cystic neoplasms are virtually always benign and it is therefore important that they are distinguished from mucinous cystic neoplasms and from intraductal papillary mucinous neoplasms. The latter two entities are associated with an invasive carcinoma in a third of the cases. PanINs can occur adjacent to any of these lesions and in this setting PanINs are important to recognize because they can lead to a misdiagnosis on biopsy or fine needle aspiration.
Incorrect
Answer: Serous cystadenoma with PanINs
Histology: The lesion is a classic serous cystadenoma. It is composed of innumerable small (1-3 mm) cysts lined by a cuboidal lining. The lining cells have a clear cytoplasm (from glycogen) and centrally placed round uniform nuclei. In addition to the serous cystadenoma, the adjacent pancreas is remarkable for pancreatic intraepithelial neoplasia (PanIN). The PanIN lesions involve the smaller pancreatic ducts and are composed of a papillary epithelium with mild to moderate atypia (PanIN-1 to PanIN-2).
Discussion: Serous cystic neoplasms are virtually always benign and it is therefore important that they are distinguished from mucinous cystic neoplasms and from intraductal papillary mucinous neoplasms. The latter two entities are associated with an invasive carcinoma in a third of the cases. PanINs can occur adjacent to any of these lesions and in this setting PanINs are important to recognize because they can lead to a misdiagnosis on biopsy or fine needle aspiration.
