220
CLINICAL IMAGING 1991;15:220-222
COEXISTENT ADENOCARCINOMA AND MICROCYSTIC ADENOMA OF THE PANCREAS HAROLD V. POSNIAK, MD, MARY C. OLSON, MD, AND TERRENCE C. DEMOS, MD
A case with coexistent pancreatic adenocarcinoma and microcystic adenoma is presented. These diagnoses were suspected on the basis of their computed tomography (CT) appearances and confirmed with CT-guided fine-needle aspiration. KEY WORDS:
Pancreas; Adenocarcinoma; Microcystic adenoma, Fineneedle aspiration
INTRODUCTION Adenocarcinoma is the most common pancreatic neoplasm. Cystic pancreatic tumors are rare. They are classified as microcystic adenomas and mutinous cystic neoplasms. We present a patient with coexistent pancreatic adenocarcinoma and microcystic adenoma. These diagnoses were suspected on the basis of their computed tomography (CT) appearances and confirmed by fine-needle aspiration. We are not aware of any previous report of the coexistence of these two lesions in the radiology literature. CASE REPORT A %-year-old woman presented with a two month history of postprandial epigastric pain and a 15pound weight loss. Her past medical history and physical examination were unremarkable. Upper gastrointestinal endoscopy and a barium enema were
From the Department of Radiology, Loyola University Medical Center, Maywood, Illinois. Address reprint requests to: Harold V. Posniak, M.D., Department of Radiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153. Received October 1990; revised January 1991. 0 1991 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899/7071/911$3.50
New York, NY 10010
normal. Laboratory studies were normal, apart from slightly elevated alkaline phosphatase of 253 (N 30110) and serum glutamic-pyruvic transaminase (SGPT) of 202 (N 4-30). A CT scan of the upper abdomen was performed during rapid infusion of 1.50 ml of Hypaque 60% (Winthrop Pharmaceuticals, New York). This demonstrated masses in the head and tail of the pancreas and several low-density hepatic masses (Figures 1,2). The mass in the pancreatic head was well-defined and measured approximately 4 cm in diameter. At least 10 cysts were visualized. These did not enhance after intravenous contrast material. The largest cyst was 1.6cm in diameter. There was no evidence of extrahepatic or pancreatic ductal dilatation. The body of the pancreas was not atrophic. The mass in the tail of the pancreas was relatively well-defined, with slight peripheral enhancement following intravenous contrast. The hepatic masses were ill-defined and enhanced slightly. There was focal intrahepatic ductal dilatation proximal to two of these masses. The CT findings suggested a diagnosis of primary adenocarcinoma of the tail of the pancreas with liver metastases and an unrelated microcystic adenoma of the head of the pancreas. Fineneedle aspiration biopsies of the pancreatic masses and a liver lesion were performed using 22 gauge spinal needles. Each lesion was aspirated twice. The aspirate from the mass in the pancreatic head differed from the other masses in that viscous fluid was drained from it, but not from the other lesions. Cytological examination of the aspirates from the mass in the pancreatic head revealed uniform cuboidal cells with small nuclei. There was no evidence of cellular atypia. Periodic-acid-Schiff (PAS) staining was positive with subsequent loss of positivity after diastase. The mucin stain was negative. These findings were consistent with a microcystic adenoma. Aspirations of the pancreztic tail mass and the liver lesion demonstrated adenocarcinoma.
JULY-SEPTEMBER
1991
PANCREATIC
FIGURE 1. Adenocarcinoma of the tail of the pancreas. CT
scan after intravenous contrast material shows an inhomogeneous mass in the tail of the pancreas (white arrows). There are several small hepatic metastases (black arrows).
DISCUSSION Adenocarcinoma of the pancreas is the fourth leading cause of death in the United States (1). It develops most frequently in the pancreatic head and least often in the tail. A focal mass is the most common CT finding. There may be central areas of decreased attenuation before and after intravenous enhancement. If extremely necrotic, it may appear cystic after enhancement. Findings proximal to the tumor may include pancreatic and bile duct dilatation, parenchymal atrophy, and pancreatitis with or without pseudocyst formation. The majority of these neoplasms are unresectable at the time of diagnosis, so that signs of advanced malignancy are usually present. These include local tumor extension, contiguous organ invasion, vascular involvement, and metastases to regional lymph nodes and the liver (2). Cystic pancreatic neoplasms are rare. They are classified as microcystic adenomas and mutinous cystic neoplasms. This differentiation is important because microcystic adenomas are benign and mucinous cystic neoplasms are either potentially or frankly malignant (3, 4, 5). Microcystic adenomas may be found anywhere in the pancreas. They are usually ovoid and well-circumscribed. The tumors are comprised of cysts that vary in size from microscopic to approximately 2 cm in diameter. Occasionally, larger cysts may be present (3, 5). Histological (6) and cytological (7) features are distinctive. The cysts are lined by a single layer of flat or cuboidal epithelial cells that are separated by fibrous septa. The cytoplasm of the cells and, in some cases the cyst fluid, contain glycogen, which is evi-
CARCINOMA
AND MICROCYSTIC
ADENOMA
221
FIGURE 2. Microcystic adenoma of the pancreatic head. CT scan 6 cm inferior to Figure 1 demonstrates a mass in the head of the pancreas (white arrows) containing several well-defined cysts. Note hepatic metastases (black arrows) and focal ductal dilation (arrowheads).
dented by PAS-positive deposits that are digested by diastase (6). Mucin is absent or negligible. The CT appearance of the tumor is variable depending on the number and size of the cysts (3). It will appear solid if the cysts are all microscopic. More often, many larger cysts with well-defined thin walls and septations produce a multilocular appearance. The softtissue components of the tumor have a rich vascular supply and enhance following intravenous contrast (4). Occasionally there is a central stellate scar or calcification. Mutinous cystic neoplasms are usually well-defined and are either unilocular or multilocular with the cysts being more than 2 cm in diameter (3). They are most frequently found in the body and tail of the pancreas. The cysts have a dense fibrous wall that is usually focally thickened. There may be papillary internal projections (4). The tumors may contain calcification that is usually peripheral (8). Histological and cytological features are similar. There is a tall mucin-producing columnar epithelium that may be benign, atypical, or malignant. The cyst fluid contains mucin. The CT features reflect the gross pathological appearance. In addition there may be local invasion and distant metastases. The most reliable CT criteria for differentiating the two types of cystic tumors are the total number of cysts and the size of the cysts. Microcystic adenomas usually have more than six cysts, whereas mutinous cystic neoplasms have six or fewer cysts (3). Internal tumor excrescences are indicative of mutinous cystic neoplasms. Calcification may be present in both groups, but is more common in microcystic adeno-
222
POSNIAK
CLINICAL IMAGING VOL. 15, NO. 3
ET AL.
mas. In microcystic adenomas the calcification is usually central, whereas it is peripheral in mutinous cystic neoplasms. A central scar, although unusual, is seen only with microcystic adenomas (3, 5). Our patient had two pancreatic masses and multiple liver lesions. The pancreatic masses had completely different features. CT clearly demonstrated the different morphology of the tumors and led to the correct diagnoses. CT-guided biopsy eliminated the need for a diagnostic or palliative surgical procedure.
E, Boring CC, Squires Cancer 1990;40:9-26.
3. Johnson CD, Stephens DH, Charboneau JW, Carpenter HA, Welch TJ. Cystic pancraetic tumors: CT and sonographic assessment. AJR 1988;151:1133-1138. 4. Minami M, Itai Y, Ohtomo K, Yoshida H, Yoshikawa K, Iio M. Cystic neoplasms of the pancreas: Comparison of MR imaging with CT. Radiology 1989;171:53-56. 5. Friedman AC, Lichtenstein JE, Dachman AH. Cystic neoplasms of the pancreas. Radiological-pathological correlation. Radiology 1983;149:45-50. 6. Mathieu D, Guigui B, Valette PJ et al. Pancreatic plasms. Radio1 Clin North Am 1989;27:163-176.
cystic neo-
7. Jones EC, Suen KC, Grant DR, Chan NH. Fine-needle aspiration cytology of neoplastic cysts of the pancreas. Diagn Cytopathol 1987;3:238-243.
REFERENCES 1. Silverberg
2. Freeny PC, Marks WM, Ryan JA, Traverso LW. Pancreatic ductal adenocarcinoma: Diagnosis and staging with dynamic CT. Radiology 1988;166:125-133.
TS. Cancer statistics,
1990.
8. Freeny PC, Lawson TL. Radiology of the Pancreas. Springer-Verlag, 1982, pp 514-539.
New York:
CLINICAL IMAGING 1991;15:220-222
COEXISTENT ADENOCARCINOMA AND MICROCYSTIC ADENOMA OF THE PANCREAS HAROLD V. POSNIAK, MD, MARY C. OLSON, MD, AND TERRENCE C. DEMOS, MD
A case with coexistent pancreatic adenocarcinoma and microcystic adenoma is presented. These diagnoses were suspected on the basis of their computed tomography (CT) appearances and confirmed with CT-guided fine-needle aspiration. KEY WORDS:
Pancreas; Adenocarcinoma; Microcystic adenoma, Fineneedle aspiration
INTRODUCTION Adenocarcinoma is the most common pancreatic neoplasm. Cystic pancreatic tumors are rare. They are classified as microcystic adenomas and mutinous cystic neoplasms. We present a patient with coexistent pancreatic adenocarcinoma and microcystic adenoma. These diagnoses were suspected on the basis of their computed tomography (CT) appearances and confirmed by fine-needle aspiration. We are not aware of any previous report of the coexistence of these two lesions in the radiology literature. CASE REPORT A %-year-old woman presented with a two month history of postprandial epigastric pain and a 15pound weight loss. Her past medical history and physical examination were unremarkable. Upper gastrointestinal endoscopy and a barium enema were
From the Department of Radiology, Loyola University Medical Center, Maywood, Illinois. Address reprint requests to: Harold V. Posniak, M.D., Department of Radiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153. Received October 1990; revised January 1991. 0 1991 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899/7071/911$3.50
New York, NY 10010
normal. Laboratory studies were normal, apart from slightly elevated alkaline phosphatase of 253 (N 30110) and serum glutamic-pyruvic transaminase (SGPT) of 202 (N 4-30). A CT scan of the upper abdomen was performed during rapid infusion of 1.50 ml of Hypaque 60% (Winthrop Pharmaceuticals, New York). This demonstrated masses in the head and tail of the pancreas and several low-density hepatic masses (Figures 1,2). The mass in the pancreatic head was well-defined and measured approximately 4 cm in diameter. At least 10 cysts were visualized. These did not enhance after intravenous contrast material. The largest cyst was 1.6cm in diameter. There was no evidence of extrahepatic or pancreatic ductal dilatation. The body of the pancreas was not atrophic. The mass in the tail of the pancreas was relatively well-defined, with slight peripheral enhancement following intravenous contrast. The hepatic masses were ill-defined and enhanced slightly. There was focal intrahepatic ductal dilatation proximal to two of these masses. The CT findings suggested a diagnosis of primary adenocarcinoma of the tail of the pancreas with liver metastases and an unrelated microcystic adenoma of the head of the pancreas. Fineneedle aspiration biopsies of the pancreatic masses and a liver lesion were performed using 22 gauge spinal needles. Each lesion was aspirated twice. The aspirate from the mass in the pancreatic head differed from the other masses in that viscous fluid was drained from it, but not from the other lesions. Cytological examination of the aspirates from the mass in the pancreatic head revealed uniform cuboidal cells with small nuclei. There was no evidence of cellular atypia. Periodic-acid-Schiff (PAS) staining was positive with subsequent loss of positivity after diastase. The mucin stain was negative. These findings were consistent with a microcystic adenoma. Aspirations of the pancreztic tail mass and the liver lesion demonstrated adenocarcinoma.
JULY-SEPTEMBER
1991
PANCREATIC
FIGURE 1. Adenocarcinoma of the tail of the pancreas. CT
scan after intravenous contrast material shows an inhomogeneous mass in the tail of the pancreas (white arrows). There are several small hepatic metastases (black arrows).
DISCUSSION Adenocarcinoma of the pancreas is the fourth leading cause of death in the United States (1). It develops most frequently in the pancreatic head and least often in the tail. A focal mass is the most common CT finding. There may be central areas of decreased attenuation before and after intravenous enhancement. If extremely necrotic, it may appear cystic after enhancement. Findings proximal to the tumor may include pancreatic and bile duct dilatation, parenchymal atrophy, and pancreatitis with or without pseudocyst formation. The majority of these neoplasms are unresectable at the time of diagnosis, so that signs of advanced malignancy are usually present. These include local tumor extension, contiguous organ invasion, vascular involvement, and metastases to regional lymph nodes and the liver (2). Cystic pancreatic neoplasms are rare. They are classified as microcystic adenomas and mutinous cystic neoplasms. This differentiation is important because microcystic adenomas are benign and mucinous cystic neoplasms are either potentially or frankly malignant (3, 4, 5). Microcystic adenomas may be found anywhere in the pancreas. They are usually ovoid and well-circumscribed. The tumors are comprised of cysts that vary in size from microscopic to approximately 2 cm in diameter. Occasionally, larger cysts may be present (3, 5). Histological (6) and cytological (7) features are distinctive. The cysts are lined by a single layer of flat or cuboidal epithelial cells that are separated by fibrous septa. The cytoplasm of the cells and, in some cases the cyst fluid, contain glycogen, which is evi-
CARCINOMA
AND MICROCYSTIC
ADENOMA
221
FIGURE 2. Microcystic adenoma of the pancreatic head. CT scan 6 cm inferior to Figure 1 demonstrates a mass in the head of the pancreas (white arrows) containing several well-defined cysts. Note hepatic metastases (black arrows) and focal ductal dilation (arrowheads).
dented by PAS-positive deposits that are digested by diastase (6). Mucin is absent or negligible. The CT appearance of the tumor is variable depending on the number and size of the cysts (3). It will appear solid if the cysts are all microscopic. More often, many larger cysts with well-defined thin walls and septations produce a multilocular appearance. The softtissue components of the tumor have a rich vascular supply and enhance following intravenous contrast (4). Occasionally there is a central stellate scar or calcification. Mutinous cystic neoplasms are usually well-defined and are either unilocular or multilocular with the cysts being more than 2 cm in diameter (3). They are most frequently found in the body and tail of the pancreas. The cysts have a dense fibrous wall that is usually focally thickened. There may be papillary internal projections (4). The tumors may contain calcification that is usually peripheral (8). Histological and cytological features are similar. There is a tall mucin-producing columnar epithelium that may be benign, atypical, or malignant. The cyst fluid contains mucin. The CT features reflect the gross pathological appearance. In addition there may be local invasion and distant metastases. The most reliable CT criteria for differentiating the two types of cystic tumors are the total number of cysts and the size of the cysts. Microcystic adenomas usually have more than six cysts, whereas mutinous cystic neoplasms have six or fewer cysts (3). Internal tumor excrescences are indicative of mutinous cystic neoplasms. Calcification may be present in both groups, but is more common in microcystic adeno-
222
POSNIAK
CLINICAL IMAGING VOL. 15, NO. 3
ET AL.
mas. In microcystic adenomas the calcification is usually central, whereas it is peripheral in mutinous cystic neoplasms. A central scar, although unusual, is seen only with microcystic adenomas (3, 5). Our patient had two pancreatic masses and multiple liver lesions. The pancreatic masses had completely different features. CT clearly demonstrated the different morphology of the tumors and led to the correct diagnoses. CT-guided biopsy eliminated the need for a diagnostic or palliative surgical procedure.
E, Boring CC, Squires Cancer 1990;40:9-26.
3. Johnson CD, Stephens DH, Charboneau JW, Carpenter HA, Welch TJ. Cystic pancraetic tumors: CT and sonographic assessment. AJR 1988;151:1133-1138. 4. Minami M, Itai Y, Ohtomo K, Yoshida H, Yoshikawa K, Iio M. Cystic neoplasms of the pancreas: Comparison of MR imaging with CT. Radiology 1989;171:53-56. 5. Friedman AC, Lichtenstein JE, Dachman AH. Cystic neoplasms of the pancreas. Radiological-pathological correlation. Radiology 1983;149:45-50. 6. Mathieu D, Guigui B, Valette PJ et al. Pancreatic plasms. Radio1 Clin North Am 1989;27:163-176.
cystic neo-
7. Jones EC, Suen KC, Grant DR, Chan NH. Fine-needle aspiration cytology of neoplastic cysts of the pancreas. Diagn Cytopathol 1987;3:238-243.
REFERENCES 1. Silverberg
2. Freeny PC, Marks WM, Ryan JA, Traverso LW. Pancreatic ductal adenocarcinoma: Diagnosis and staging with dynamic CT. Radiology 1988;166:125-133.
TS. Cancer statistics,
1990.
8. Freeny PC, Lawson TL. Radiology of the Pancreas. Springer-Verlag, 1982, pp 514-539.
New York:
