Pancreatic cystic manifestations in von Hippel-Lindau disease

Benign Tumors and Tumorlike Lesions of the Pancreas

The pancreas is a complex organ that may give rise to large number of neoplasms and non-neoplastic lesions. This article focuses on benign neoplasms, such as serous neoplasms, and tumorlike (pseudotumoral) lesions that may be mistaken for neoplasm not only by clinicians and radiologists, but also by pathologists. The family of pancreatic pseudotumors, by a loosely defined conception of that term, includes a variety of lesions including heterotopia, hamartoma, and lipomatous pseudohypertrophy. Autoimmune pancreatitis and paraduodenal ("groove") pancreatitis may also lead to pseudotumor formation. Knowledge of these entities will help in making an accurate diagnosis.

Current perspectives on pancreatic serous cystic neoplasms: Diagnosis, management and beyond

Pancreatic cystic neoplasms have been increasingly recognized recently. Comprising about 16% of all resected pancreatic cystic neoplasms, serous cystic neoplasms are uncommon benign lesions that are usually asymptomatic and found incidentally. Despite overall low risk of malignancy, these pancreatic cysts still generate anxiety, leading to intensive medical investigations with considerable financial cost to health care systems. This review discusses the general background of serous cystic neoplasms, including epidemiology and clinical characteristics, and provides an updated overview of diagnostic approaches based on clinical features, relevant imaging studies and new findings that are being discovered pertaining to diagnostic evaluation. We also concisely discuss and propose management strategies for better quality of life.

HYPOCALCEMIA: A RARE COMPLICATION OF VON HIPPEL-LINDAU DISEASE

von Hippel-Lindau disease is a hereditary neoplastic syndrome, characterized by malignant and benign lesions in multiple organs. Pancreatic involvement is very common and is in general asymptomatic. We describe a case of malabsorption with severe hypocalcemia in a patient with von Hippel-Lindau disease, caused by exocrine pancreatic insufficiency, probably due to severe cystic transformation of the pancreas.

Contiguous haemangioblastomas of the brain and spine in a patient of Von Hippel-Lindau disease

Von Hippel-Lindau (VHL) disease is an inherited, autosomal-dominant syndrome caused by heterozygous germline mutations in the VHL gene, and predisposing to the development of benign and malignant tumours and cysts in multiple organ systems involving eyes, kidneys, pancreas, liver and central nervous system. The responsible tumour suppressor gene for VHL disease is in chromosome 3p25. We are presenting a case of a patient with both cerebellar as well as spinal haemangioblastoma in addition to polycystic pancreas. We operated on both the spinal and the cerebellar haemangioblastomas and the patient had made a very good recovery. We present this case for its rarity along with the literature review.

Microcystic serous cystadenoma of the pancreas with subtotal cystic degeneration: another neoplastic mimic of pancreatic pseudocyst

BACKGROUND

Pancreatic serous cystadenomas are benign cystic neoplasms. Extensive degeneration mimicking a pancreatic pseudocyst has been described in several types of pancreatic neoplasms but has not been documented in serous cystadenomas. We report subtotal cystic degeneration of microcystic serous cystadenomas (MSCA) that produces radiographic, gross, and microscopic overlap with pancreatic pseudocyst.

MATERIALS AND METHODS

Resected MSCA with degenerative change were identified from the pathology archives of Memorial Sloan-Kettering Cancer Center and Johns Hopkins Hospital. The clinical, radiographic, gross, and microscopic findings were reviewed.

RESULTS

Eight MSCAs with subtotal cystic degeneration were retrieved from among 397 resected serous cystadenomas (2.0%). There were 2 men and 6 women (mean age, 52 y). Available radiographic studies showed classic features of MSCA in 2 of 4 cases. Four cysts were unilocular, and 4 were multilocular. Gross features of MSCA were noted focally in the multilocular cases but were not evident in the unilocular examples. The predominant histologic features were those of pancreatic pseudocyst, including a fibrotic cyst wall lacking epithelium and instead composed of myofibroblastic proliferation, hemorrhage, and inflammation. Residual foci of MSCA were embedded in fibrosis, comprising 5% to 60% of the tumor volume.

CONCLUSIONS

Most pancreatic serous cystadenomas display characteristic morphology, including a glycogen-rich epithelial lining and prominent subepithelial capillaries; however, extensive degenerative macrocystic change can obscure these classic features. This phenomenon is to be distinguished from macrocystic serous cystadenoma, in which thin-walled macrocystic spaces are epithelium lined. Thus, serous cystadenoma should be included in the differential diagnosis of pancreatic masses with extensive degenerative cystic change.

Calponin is expressed in serous cystadenomas of the pancreas but not in adenocarcinomas or endocrine tumors

The diagnosis of serous microcystic adenoma (SMA) is usually straightforward. For small biopsies and/or unusual variants, the differential diagnosis includes other pancreatic or metastatic neoplasms showing cystic or clear cell features. We evaluated immunostains for potential use in the diagnosis of SMA. Cases of SMA were identified from archival files. Tissue cores (2 per block) were arrayed to create a microarray of cores measuring 2mm each. Additionally, microarrays previously constructed from 56 pancreatic adenocarcinomas (PACs) and 64 pancreatic endocrine tumors (PENs) were studied. The microarrays were stained with calponin, chromogranin, CD10, alpha-inhibin, and monoclonal neuron-specific enolase (m-NSE). Subsequently, some were stained with MUC6, melan-A, D2-40, h-caldesmon, smooth muscle actin, and smooth muscle myosin. For SMAs, staining was seen with calponin (85.2%), alpha-inhibin (96.2%), and m-NSE (96.2%). Focal weak staining was seen with MUC6 (65%). All SMAs were negative with chromogranin, CD10, melan-A, D2-40, h-caldesmon, smooth muscle actin, and smooth muscle myosin. In contrast, calponin was negative in all PACs and PENs. Staining for alpha-inhibin was absent in PACs and present in 4.1% of PENs; whereas immunoreactivity for m-NSE was present in 26.8% of PACs and 73.7% of PENs. Chromogranin staining was present in 9.1% of PACs and 100% of PENs. An immunohistochemical profile of staining with calponin, alpha-inhibin, and m-NSE and absent staining with chromogranin supports the diagnosis of SMA, and distinguishes SMA from PAC and PEN. Calponin and alpha-inhibin are the most useful positive markers for SMA, and are negative in most entities in the differential diagnosis.

Inherited pancreatic endocrine tumor syndromes: advances in molecular pathogenesis, diagnosis, management, and controversies

Pancreatic endocrine tumors (PETs) can occur as part of 4 inherited disorders, including Multiple Endocrine Neoplasia type 1 (MEN1), von Hippel-Lindau disease (VHL), neurofibromatosis 1 (NF-1) (von Recklinghausen disease), and the tuberous sclerosis complex (TSC). The relative frequency with which patients who have these disorders develop PETs is MEN1>VHL>NF-1>TSC. Over the last few years, there have been major advances in the understanding of the genetics and molecular pathogenesis of these disorders as well in the localization and the medical and surgical treatment of PETs in such patients. The study of PETs in these disorders not only has provided insights into the possible pathogenesis of sporadic PETs but also has presented several unique management and treatment issues, some of which are applicable to patients with sporadic PETs. Therefore, the study of PETs in these uncommon disorders has provided valuable insights that, in many cases, are applicable to the general group of patients with sporadic PETs. In this article, these areas are reviewed briefly along with the current state of knowledge of the PETs in these disorders, and the controversies that exist in their management are summarized briefly and discussed.

Serous cystadenoma of the pancreas: clinical and pathological features in 33 patients

AIM

To report the clinicopathological features of patients with serous cystadenomas of the pancreas.

METHODS

Thirty-three cases of serous cystadenoma diagnosed between 1977 and 2006 were retrieved from the files of the Ohio State University Medical Center. Clinical data and microscopic slides were reviewed.

RESULTS

The patients included 27 women and 6 men with an age range of 38-83 (mean 64.3) years. The clinical presentation included 13 patients with abdominal pain and 8 patients with abdominal mass; 9 tumors were found incidentally. Abdominal CT scans in 25 patients were interpreted as suspicious for carcinoma in 8 (32%), suspicious for serous cystadenoma in 8, neoplasm not otherwise specified in 8, and suspicious for a pseudocyst in 1. Only 7 patients underwent a preoperative biopsy, and 5 of these were diagnosed as having a serous cystadenoma. All but 2 of the patients underwent surgical resection of the tumor. The serous cystadenomas varied in size from 1.0 to up to 13 cm in maximum dimension, and all but one had a multicystic appearance. Of the 33 serous cystadenomas, 20 (61%) were located in the pancreatic tail, 4 (12%) in the pancreatic body, 4 in the pancreatic body and tail, and 5 (15%) in the head of the pancreas. Follow-up in 17 patients (median 3 years, range from 1 month to 11 years) showed no recurrence of serous cystadenomas. One patient had von Hippel-Lindau syndrome, 4 patients had diabetes mellitus, 3 patients had metastatic cancer, and 2 patients had ovarian tumors.

CONCLUSIONS

Serous cystadenoma is an uncommon neoplasm that can be confused with malignancy both clinically and radiologically; a correct diagnosis is important in order to provide an accurate prognosis.

Presentation and management of pancreatic cystic neoplasms

Pancreatic cystic neoplasms are less frequent than other pancreatic tumors, but because of the wide availability and improvement of modern imaging methods, these neoplasms are being recognized with increasing frequency and it is often possible to be differentiated preoperatively not only from other cystic pancreatic disorders but also from one another. Most patients have no symptoms while clinical signs are not really useful in the clinical work up, and when they are present, they never help us to identify the type of pathology. Treatment differs with the diagnosis. Serous cystic neoplasms are uniformly benign and usually do not mandate resection unless this lesion is symptomatic. In contrast, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have a premalignant or malignant tendency, and therefore should be managed aggressively by pancreatic resection; in the absence of invasive disease, prognosis is excellent after appropriate surgery, but the presence of invasive malignancy signifies a poor prognosis. Solid pseudopapillary neoplasms have nonaggressive behavior and their management is related to the extension of the disease. The purpose of this article is to review the types of pancreatic cystic neoplasms, their diagnosis, indications for surgical treatment, and outcome.

Microcystic serous cystadenoma of the pancreas: a report of two cases with one of diffuse presentation

Microcystic adenoma or serous cystadenoma is an uncommon tumor and accounts for 1-2% of the exocrine neoplasms of the pancreas. Usually unifocal, they present as single, large, well-demarcated multiloculated cystic tumors, ranging in size from 1 to 25 cm. Multifocal variants or diffuse serous cystadenomas are extremely rare. We present 2 cases of which 1 is a diffuse variant affecting the body, tail and part of the neck of the pancreas. In both the patients the tumors were detected incidentally. We highlight on the diffuse variant in view of its rarity and present a review of literature. In this case the entire body and tail of the pancreas was spongy replaced by multicystic lobules and hyalinized fibrocollagenous stroma. The cysts were lined by low cuboidal glycogen containing bland cells. Such a unique presentation wherein the entire body and tail of the pancreas is replaced with multiple cysts is a diffuse presentation of microcystic adenoma and a search through literature revealed only 7 such cases among the 15 cases with multifocal presentation reported.

Histology of cystic tumors of the pancreas

The cystic tumors of the pancreas constitute a considerable diagnostic challenge because of their overlapping clinical, radiologic, and pathologic features. They may be difficult to differentiate from one another and from benign lesions such as pseudocysts. Because many of the tumors in this group are potentially curable, correct diagnosis is essential for proper patient management. Even when correctly diagnosed, thorough microscopic evaluation is required for the mucin-producing tumors to correctly determine their degree of malignant progression in any given case. Most recently, molecular analysis of these tumors has demonstrated definitively that the serous and mucinous types of cystic neoplasms of the pancreas are unrelated pathogenetically. Conversely, molecular data indicate similarities between the mucinous types of cystic tumors and ductal adenocarcinoma of the pancreas, but the essential molecular differences that underlie the differences in biological behavior are as yet undetermined.

Pancreatic cysts: depiction on single-shot fast spin-echo MR images

PURPOSE

To evaluate single-shot fast spin-echo (SE) magnetic resonance (MR) imaging for depiction of pancreatic cysts in a large number of patients and to analyze cyst prevalence with respect to patient age and sex and other clinical information.

MATERIALS AND METHODS

Single-shot fast SE images of the pancreas were obtained in 1,444 patients. The images were reviewed for presence of pancreatic cysts, which were classified as simple and nonsimple types, and cyst diameters were measured. kappa statistic, Fisher exact, McNemar Q, and Pearson product moment correlation tests were performed.

RESULTS

Two hundred eighty-three (19.6%) patients had at least one pancreatic cyst. The prevalence of pancreatic cysts increased with age (r = 0.96). The percentages of male and female patients with pancreatic cysts (20.4% vs 18.8%) were not significantly different. Two hundred seventy-one (18.8%) patients had simple cysts, and 147 (10.2%) had nonsimple cysts. Of 283 patients with pancreatic cysts, 158 (55.8%) had only one pancreatic cyst. The number of patients with multiple cysts increased with age after 70 years. Four hundred fifteen (83.8%) cysts were 10 mm in diameter or smaller; 56 (11.3%), 11-20 mm in diameter; and 24 (4.9%), 21 mm in diameter or larger. Sixteen (5.7%) patients with pancreatic cysts had malignant pancreatic tumors, and 75 (26.5%) patients had pancreatitis.

CONCLUSION

The prevalence of pancreatic cysts at single-shot fast SE MR imaging-especially cysts with a diameter smaller than 10 mm-is similar to that of pancreatic cysts at autopsy and higher than that of pancreatic cysts at transabdominal ultrasonography. Prevalence is especially high in patients with pancreatitis.

von Hippel-Lindau disease

In recent years advances have been made in the clinical and genetic aspects of von Hippel-Lindau disease (VHL). Retinal capillary hemangioma is the most common manifestation of VHL disease and, therefore, ophthalmologists are frequently involved in the care of patients with this disease. The incidence of VHL disease is approximately 1 in 40,000 live births. It is estimated that there are approximately 7000 patients with VHL disease in the USA. The inheritance of VHL disease is autosomal dominant with high penetrance. Depending on the clinical circumstances, retinal capillary hemangioma may be managed by observation, laser photocoagulation, cryotherapy, and plaque radiotherapy. Typical extraocular lesions associated with VHL disease are central nervous system hemangioma, renal cyst, renal carcinoma, pancreatic cysts and adenoma, pancreatic islet cell tumors, pheochromocytoma, endolymphatic sac tumor of the inner ear, and cystadenoma of the epididymis and the broad ligament. The life expectancy of affected individuals may be improved by early detection and treatment of varied manifestations with the use of surveillance protocols. Identification of the VHL gene on chromosome 3p25-26 has now made it possible for suspected individuals to undergo genetic testing with a high degree of accuracy. We review herein the ophthalmic manifestations and treatment of retinal capillary hemangioma and systemic findings of the VHL disease.

Pancreatic involvement in von Hippel-Lindau disease. The Groupe Francophone d'Etude de la Maladie de von Hippel-Lindau

BACKGROUND & AIMS

Pancreatic involvement in von Hippel-Lindau (VHL) disease, a genetic disorder with a dominant mode of inheritance affecting various organs, has rarely been studied. We assessed the prevalence, type of lesions, natural history, and impact of pancreatic involvement in patients with VHL.

METHODS

A total of 158 consecutive patients from 94 families with VHL disease were studied in a prospective French collaborative study. All patients underwent systematic screening for VHL lesions, including computerized tomography (CT) scanning of the pancreas reviewed by an experienced radiologist. Clinical data, investigations, and treatments performed were also reviewed.

RESULTS

Pancreatic involvement was observed in 122 patients (77.2%) and included true cysts (91.1%), serous cystadenomas (12.3%), neuroendocrine tumors (12.3%), or combined lesions (11.5%). The pancreas was the only organ affected in 7.6% of patients. Patients with pancreatic lesions had fewer pheochromocytomas than those without (14/122 vs. 16/36; P<0.0001), and patients with neuroendocrine pancreatic tumors had renal involvement less often than those without (8/99 vs. 6/20; P = 0.013). None of the patients with neuroendocrine tumors had symptoms of hormonal hypersecretion. Pancreatic lesions evolved in half of patients but required specific treatment in only 10 (8.2%) when they were symptomatic or for the resection of large neuroendocrine tumors.

CONCLUSIONS

Pancreatic involvement is seen in most patients with VHL disease. Although symptoms are rare, specific treatment of pancreatic lesions is required in selected patients, mainly those with neuroendocrine tumors.

[Cystic lesions of the pancreas]

Most cystic lesions of the pancreas are pseudocysts caused by acute or chronic pancreatitis. Congenital cysts are rare and may occur in congenital syndromes like von Hippel-Lindau syndrome. Cystic tumors of the pancreas may be difficult to distinguish clinically; however, because of their malignant potential, in particular in cases of mucinous types, diagnostic verification is crucial. Hence, in all cases of cystic lesions of the pancreas, which are not a sequela of an etiological confirmed acute or chronic pancreatitis, a cystic neoplasm must be ruled out. Differential diagnosis may be difficult even with ultrasonography, computertomography, endoscopic retrograde cholangiopancreatography and serum analyses; endoscopic ultrasound, magnetic resonance tomography and analysis of the cyst content may be of particular value. The therapeutic approach for pseudocysts is now well established and guided by symptoms and complications. If a cystic neoplasm is suspected, surgical resection of the complete lesion is warranted.

CONCLUSION

The most important differential diagnosis in all cystic lesions of the pancreas with atypical presentation includes a cystic neoplasm. Therefore complete resection is indicated whenever the suspicion cannot be ruled out.