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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 3  |  Page : 408-410
Serous microcystic adenoma of the pancreas


1 Department of Pathology, J N Medical College and KLESH-MRC, Belgaum, India
2 Department of Gastroenterology, J N Medical College and KLESH-MRC, Belgaum, India

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Date of Web Publication12-Aug-2009
 

   Abstract 

Serous microcystic adenoma (SMA) is a rare benign neoplasm. It accounts for 1-2% of all exocrine pancreatic tumors. It is thought to arise from the ductal epithelial cells. It is usually located in the body and the tail of the pancreas. It is important to identify SMAs and distinguish them from mucinous cystic neoplasm, which can be premalignant or malignant, and pseudocyst, which is a non neoplastic condition. We present one such rare case of SMA occurring in the head of the pancreas, an infrequent location requiring a Whippel's resection.

Keywords: Microcystic adenoma, pancreas, serous cyst adenoma, tumor

How to cite this article:
Malur PR, Suranagi VV, Bannur HB, Kulgod S. Serous microcystic adenoma of the pancreas. Indian J Pathol Microbiol 2009;52:408-10

How to cite this URL:
Malur PR, Suranagi VV, Bannur HB, Kulgod S. Serous microcystic adenoma of the pancreas. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Nov 23];52:408-10. Available from: http://www.ijpmonline.org/text.asp?2009/52/3/408/55010



   Introduction Top


Serous microcystic adenoma (SMA), also known as glycogen-rich cyst adenoma or serous cyst adenoma, is a rare benign neoplasm, constituting about 1-2% of all exocrine pancreatic tumors. [1],[2] It usually occurs in the 7 th to 8 th decade of life, with a striking female predominance (70%). [1] Most of these neoplasms are located in the body and the tail of the pancreas. [1],[3],[4] We present a rare case of microcystic adenoma occurring in the head of the pancreas, which is an uncommon location.


   Case Report Top


A 65-year-old female presented with a 4-week history of abdominal pain and vomiting. The pain aggravated after taking food. The patient's medical history was significant for hypertension. On physical examination, the patient had tenderness in the left upper abdomen and a vague lump could be palpated. Ultrasonography (USG) revealed an approximately 8cm mass involving the pancreatic head region, pushing the portal vein anteriorly. No abnormality was detected on routine blood examination and urine examination, except that her erythrocyte sedimentation rate was raised to 58mm at the end of 1 st hour. Her chest X-ray was normal. Exploratory laparotomy was performed. A large cystic mass was present in the head of the pancreas. Part of the cyst wall was adherent to the portal vein, which was carefully separated. Whipple's procedure was performed. Post operative period was uneventful.

Pathologic findings

Specimen received at the surgical pathology laboratory included the antral part of the stomach, duodenum, gall bladder and head of the pancreas. The mass measured 8 cm 7 cm 5cm. The cut surface revealed multiple cysts of varying sizes ranging between 0.5 and 2 cm in diameter, which contained hemorrhagic fluid [Figure 1].

Microscopic examination revealed cystic structures lined by cuboidal cells with clear cytoplasm and round centrally placed nuclei and inconspicuous nucleoli [Figure 2]. Focal areas of intracystic papillary projections were seen. The cells lacked atypia and contained intracytoplasmic glycogen granules, which were demonstrated by Periodic acid Schiff (PAS) stain. They were resistant to diastase digestion. The wall of the cyst, the stroma and the adjacent pancreatic tissue showed chronic inflammation and fibrosis. The gall bladder, duodenum and antrum of the stomach also revealed chronic inflammation.


   Discussion Top


Cystic neoplasms of the pancreas are uncommon, constituting 5% of all the pancreatic neoplasms and accounting for about 10-15% of all cystic pancreatic lesions. [5] Serous cyst adenomas account for 25% of all the cystic tumors of the pancreas. [4] The World Health Organization has classified them into SMAs and serous oligocystic adenomas. [6] SMA usually has many tiny cysts, frequently more than six loculi, measuring less than 2cm in diameter. Oligocystic adenomas have a few cysts, usually measuring more than 2cm in diameter. [4]

The head of the pancreas is an uncommon location for SMA as compared with the body and tail. The size varies between 1 and 25cm. [2] The origin of the cells remain unclear although previous histological and ultrastructural studies suggest a centroacinar cell or a ductal cell origin. [1]

SMAs and cysts of the pancreas may occur sporadically or as a part of the Von Hippel Lindau disease in 35-75% of the cases. [7] Occasionally, SMAs can be associated with pancreatic adenocarcinoma, pancreatic endocrine tumor [3] and stromal amyloid deposits. [8] Two-thirds of the patients with SMA present with abdominal pain, abdominal mass, nausea, vomiting or weight loss. The remaining one-thirds is discovered incidentally on examination, USG, autopsy or computed tomography (CT) scan. [4],[5]

Radiographic differentiation is attempted on the basis of mass size, calcification and the number of cysts. Differential diagnosis would include pancreatic carcinoma, lymphoma and pseudocyst. [5] It is important to distinguish SMA and mucinous cystic neoplasm because the latter ranges from premalignant to malignant, which can be diagnosed by USG/CT findings/fine needle aspiration cytology. On plain CT, a sunburst pattern of calcification with central scar is pathognomonic, occurring in up to 30% of the patients. In contrast to the SMA, which has intratumoral calcifications, mucinous tumors and pseudocysts may have peripheral calcification. [8] Mucinous cyst adenomas have few large loculi with thin septa.

Biochemical analysis of the cyst fluid includes amylase and tumor markers, such as carcinoembryonic antigen, NB/70k, CA 72-4, CA 125, etc. Amylase content of the fluid in SMA is usually lower than the levels in the pseudocyst and mucinous cystic tumor. Also, SMA has lower levels of tumor markers compared with mucinous tumors. Most pseudocysts have a history of pancreatitis. Communication of the pseudocyst with the pancreatic duct is observed in 70% of the cases by endoscopic retrograde pancreatography, in contrast to SMAs that lack communication. [4] Despite multiple modality approaches, diagnosis of SMA can be made in only about 40% of the cases. [9]

Histologically, SMAs are characterized by microcystic architecture lined by a cuboidal epithelium. The cytoplasm contains glycogen, which can be demonstrated with PAS stain and confirmed with amylase. Immunohistochemically, they are positive for CA199 and B 72.3. Electron microscopy reveals epithelial cells connected by an occluding junction and belt desmosomes resting on a basement membrane with numerous glycogen granules in the cytoplasm. Zymogen and neurosecretory granules are absent, supporting a ductal cell origin. [1]

SMAs invariably have a benign course. However, a case of SMA having malignant potential has been reported. [10] Hence, conservative management has a risk of hemorrhage, erosion into adjacent structures and biliary obstruction. [11] Tumors in the body and tail of the pancreas require distal pancreatectomy. Whippel's resection remains the surgical procedure of choice for the patients with tumors in the head or uncinate process of the pancreas. [9] Tumors in the body and tail are known to have a better outlook. [4]

 
   References Top

1.Omeroglu, Atilla, Paner, Gladell P, Ciesta, Marlyn C, Hartman, Grace. Serous micro cystic adenoma of the pancreas. Arch Pathol Lab Med 2001;125:1613-4.  Back to cited text no. 1    
2.Chandralekha T, Prashant M, Rajiv S, Palepu J, Arthur Z. Micro cystic serous cyst adenoma of the pancreas: A report of two cases with one of diffuse presentation. Pancreatology 2006;6:248-53.  Back to cited text no. 2    
3.Slukin I.I, Hafez GR, Niederhuber JE, Warner TF. Combined micro cystic adenoma and well differentiated endocrine pancreatic neoplasm: A case report and review of literature. Arch Pathol Lab Med 2003;127:1369-72.  Back to cited text no. 3    
4.Aydin S, Mehmet A, Nesrin T, Omer FY, Fahtrettin K, Musa A, Burhan. Serous micro cystic adenoma of the pancreas: Case report and review of literature. Turk J Gastroenterol 2004;15:183-6.  Back to cited text no. 4    
5.Shivram S, Nagar A, Uppal R, Karmalkar H, Phatak S. Micro cystic adenoma of pancreas. Abdominal 2005;15:437-8.  Back to cited text no. 5    
6.World Health Organization International Histological Classification of Tumors. In: Kloppel G, Solcia E, Longnecker DS, editors. Histologic typing of Tumors of the Exocrine Pancreas. 2nd ed. Berlin: Springer-Verlag, 1996.  Back to cited text no. 6    
7.Victoria HM, Alexander OV, Zhengping Z, Steven KL, McClellan MW, Peter LC, et al. Histopathology and Molecular Genetics of multiple cysts and Micro cystic adenomas of the pancreas in Von Hippel Lindau patients. Am J Pathol 2000;157:1615-21.  Back to cited text no. 7    
8.Tripodi SA, Civitelli S, Scurfeld K, Cintorino M. Micro cystic adenoma of the pancreas with stromal amyloid deposits. Histopathology 2000;37:147-9.  Back to cited text no. 8    
9.Pyke CM, Van Heerden JA, Colby TV. The spectrum of serous cyst ad enoma of the pancreas: Clinical pathologic and surgical aspects. Ann Surg 1992;215:132-9.  Back to cited text no. 9    
10.Abe H, Kubota K, Mori M, Miki K, Minangawa M, Noie T, et al . Serous cyst adenoma of the pancreas with invasive growth. Benign or malignant? Am J Gastroenterol 1998; 93:1963-6.  Back to cited text no. 10    
11.Borgne JL, Calan L, Partensky C. Cyst adenomas and cystadenocarcinomas of the pancreas. Ann Surg 1999;230:152-61.  Back to cited text no. 11    

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Correspondence Address:
Vijayalaxmi V Suranagi
A-14/11, JNMC Staff Quarters, Nehru nagar, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.55010

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    Figures

  [Figure 1], [Figure 2]

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