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Serous Neoplasms of the Pancreas: A Clinicopathologic Analysis of 193 Cases and Literature Review With New Insights on Macrocystic and Solid Variants and Critical Reappraisal of So-called “Serous Cystadenocarcinoma

Reid, Michelle D. MD*; Choi, Hye-Jeong MD; Memis, Bahar MD*; Krasinskas, Alyssa M. MD*; Jang, Kee-Taek MD; Akkas, Gizem MD*; Maithel, Shishir K. MD§; Sarmiento, Juan M. MD§; Kooby, David A. MD§; Basturk, Olca MD; Adsay, Volkan MD*

The American Journal of Surgical Pathology: December 2015 - Volume 39 - Issue 12 - p 1597–1610
doi: 10.1097/PAS.0000000000000559
Original Articles

The literature on “variants” and “malignant” counterparts of pancreatic serous cystic neoplasms (SCNs) is highly conflicted. Clinicopathologic characteristics of 193 SCNs were investigated, along with a critical literature review. For the macrocystic (oligocystic) variant, in this largest series, a demographic profile in contrast to current literature was elucidated, with 21% frequency, predominance in female individuals (4:1), body/tail location (1.7×), younger age of patients (mean age, 50 y), and frequent radiologic misdiagnosis as other megacystic neoplasms. Solid SCNs were rare (n=4, 2%) and often misinterpreted radiologically as neuroendocrine tumors. Available fine-needle aspiration in 11 cases was diagnostic in only 1. Radiologic impression was “malignancy” in 5%. Associated secondary tumors were detected in 13% of resections, mostly neuroendocrine. Secondary “infiltration” (direct adhesion/penetration) of spleen, stomach, colon, and/or adjacent nodes was seen in 6 (3%) fairly large SCNs (mean, 11 cm) with no distant metastasis. Three SCNs recurred locally, but completeness of original resection could not be verified. Our only hepatic SCN lacked a concurrent pancreatic tumor. Literature appraisal revealed that there are virtually no deaths that are directly attributable to dissemination/malignant behavior of SCNs, and most cases reported as “malignant” in fact would no longer fulfill the more recent World Health Organization criteria but instead would represent either (1) local adhesion/persistence of tumor, (2) cases with no histologic verification of malignancy, or (3) liver SCNs with benevolent behavior (likely representing multifocality, rather than true metastasis, especially considering there was no fatality related to this and no reported metastases to other remote sites). In conclusion, in contrast to the literature, the clinicopathologic characteristics of solid and macrocystic SCN variants are similar to their microcystic counterpart, although their radiologic diagnosis is challenging. Recurrence/secondary invasion of neighboring organs occurs rarely in larger SCNs but seems innocuous. An SCN should not be classified as “malignant” unless there is clear-cut evidence of histologic malignancy or documented distant metastasis.

Departments of *Pathology

§Surgery, Emory University Hospital, Atlanta, GA

Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY

Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan

Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

M.D.R. and H.-J.C. are co-contributing first authors of the manuscript.

Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Volkan Adsay, MD, Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Room H-180B, Atlanta, GA 30322 (e-mail: nadsay@emory.edu).

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