Serous cystic neoplasm of pancreas with surgical obstructive jaundice and double duct sign: Cystadenoma or cystadenocarcinoma?

Excerpt

Serous cystic neoplasm (SCN) is a cystic lesion of the pancreas, with a large number of patients being diagnosed incidentally. It is generally considered a benign entity, with limited cases of serous cystadenocarcinoma reported in literature [1]. There is no clear pathological characteristic to differentiate cystadenoma or cystadenocarcinoma even with local invasion on radiological imaging in the absence of distant metastasis [2]. A 63-year-old male presented with surgical obstructive jaundice (SOJ) and pruritis with no history of cholangitis and weight loss for one month. Blood investigations revealed conjugated hyperbilirubinemia (total and conjugated bilirubin levels of 6.4 mg/dL and 4.9 mg/dL, respectively, and a raised alkaline phosphatase of 396 IU/mL). Radiological investigations showed a large microcystic lesion in the head of the pancreas with mild attenuation in the portal vein (PV) caliber and close abutment of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) with overall features suggestive of an SCN (Fig. 1). However, findings such as a positive double duct sign and involvement of adjacent vascular structures along with the clinical presentation of SOJ were suspicious for malignancy. The patient was successfully managed with classical pancreaticoduodenectomy with sleeve resection of superior mesenteric vein and portal vein with longitudinal venorrhaphy (Fig. 2A). A replaced right hepatic artery (rRHA) was seen coursing through the tumor and had to be sacrificed owing to an inadequate stump of the gastroduodenal artery to allow reconstruction after ensuring a good pulsatile back-bleed from the distal part of the artery. The final histopathological report revealed serous cystadenoma with negative margins (Fig. 2B). SCN rarely presents with SOJ [3]. Distant metastasis is the only definitive sign of cystadenocarcinoma; radiological double duct sign along with locally aggressive features such as involvement of adjacent vascular structure does not always favor cystadenocarcinoma or exclude cystadenoma; however, surgical resection with negative margins should be the aim.

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