Aggressive Cystic Adenocarcinoma of Pancreas

A 65-year-old male patient was hospitalised with the complaints of nausea, vomiting, abdominal pain and unintentional weight loss over the past several months. A CT scan of the abdomen was performed.

CT abdomen – Revealed a large cystic mass with central necrosis involving the body and the tail of the pancreas encroaching onto the left kidney and the spleen. PET/CT – Showed a large FDG avid mass with central photopenia corresponding to the subcapsular fluid collection around the spleen.

A. Background
Pancreatic masses can appear solid or cystic on imaging. The differential diagnosis for the solid pancreatic masses include pancreatic adenocarcinoma, neuro-endocrine tumours or metastasis, whereas cystic masses include pseudo cyst, intraductal papillary mucinous neoplasm (IPMN), serous cystadenoma and mucinous cystic neoplasms (MCN). [1]

B. Clinical Perspective
Pancreatic adenocarcinoma typically present as solid mass, can however rarely present (8%) as cystic tumours [4].  Pancreatic adenocarcinoma is an aggressive cancer that presents with abdominal pain, weight loss and jaundice [1]. Our patient presented with abdominal pain, vomiting and weight loss. A CT scan and biopsy confirmed pancreatic adenocarcinoma.

C. Imaging Perspective
Current guidelines recommend the use of computerised tomography and/or magnetic resonance imaging as initial modality when pancreatic cancer is suspected. Other imaging techniques including endoscopic ultrasound and ERCP can be used for the further evaluation of the mass. Increasing use of these imaging techniques has led to increased incidence of pancreatic cysts [2]. 2.2% of abdominal CT scans performed annually reveal pancreatic cysts [1]. Among the pancreatic cystic lesions, IPMN and MCN carry increased risk of malignant transformation with 12%-47% and 10-17% respectively [1,3]. Utilising imaging modalities to identify and characterise pancreatic cysts is invaluable for an early diagnosis and appropriate management. A CT scan performed in our patient was invaluable in identifying the underlying diagnosis.

D. Outcome
    Surgery with or without adjuvant chemotherapy is the mainstay in the management of pancreatic cancers, but unfortunately 75% of them present with unresectable disease [5]. Our patient received chemotherapy as the mass was unresectable due to its size and multiorgan involvement. The patient unfortunately succumbed to death eight months following chemotherapy.

E. Take Home Message
Pancreatic adenocarcinoma typically present as a solid lesion on imaging, however it can rarely present with cystic features. Utilising imaging tests carefully to identify and characterise the cystic masses of the pancreas helps a physician to plan appropriate management of this aggressive tumour in a timely manner.

Written informed patient consent for publication was obtained.