Solid serous cystic neoplasm of the pancreas with invasive growth
Solid serous cystic neoplasm of the pancreas with invasive growth
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具有侵袭性生长的胰腺实性浆液性囊性肿瘤
DOI：
10.1007/s00534-012-0575-x
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发表时间：
2013
影响因子：
3
通讯作者：
E. Hong
中科院分区：
文献类型：
--
作者：
Seung Duk Lee;Sung;E. Hong
一位56岁男性因胰腺肿块来本院就诊，此肿块是在例行体检时偶然发现的。他没有潜在的疾病，否认吸烟、酗酒或有恶性肿瘤家族史。此外，体检未发现任何症状或异常。实验室检测显示没有异常发现。CEA、CA19-9等肿瘤标志物正常。动脉期腹部计算机断层扫描显示胰腺尾部有一个2.1厘米强化的实性肿块，毗邻脾静脉(图1a，箭头)。肿瘤在CT门脉期仍有强化(图1B)。胰腺神经内分泌瘤是强烈怀疑的放射学发现。采用四针入路行腹腔镜下胰腺远端切除术。大体病理显示胰腺尾部有2.5 9 2.0 9 1.3 cm的实性肿块，呈黄白色坚固，边缘模糊。肿瘤毗邻胰腺包膜上缘(图1C)。胰腺组织学检查显示，实性肿瘤由排列紧密的立方或多边形细胞的腺体结构组成，其中许多细胞胞质清晰(图2a)。高碘酸席夫氏(PAS)染色在细胞质内呈弱阳性(图2B)。细胞核均匀细小，呈圆形，染色较深。未发现有丝分裂、细胞学异型性或乳头状生长模式。很少观察到微囊成分。肿瘤侵犯周围胰腺和胰周软组织，无包膜，常见胰岛卡压和神经侵袭(图2C)。肿瘤侵犯邻近脾静脉(图2D)。但未发现有淋巴结转移。免疫组织化学染色显示肿瘤细胞CK7、CK19和MUC-6阳性，突触素阴性。腺瘤区域被一条宽阔的致密纤维间质隔开(图3A)。间质显示丰富的平滑肌肌动蛋白(SMA)阳性的肌成纤维细胞(图3B)。手术后12个月，病人恢复得很好。自从1996年首次描述以来，实性SCN一直被认为是浆液性囊性肿瘤的一种亚型，缺乏分泌能力和浆液性囊腺瘤独特的囊性结构[1]。该肿瘤的细胞学和免疫组织化学特征与浆液性囊腺瘤难以区分。报道的11例实性SCN均与邻近的正常胰腺和血管边界清楚[1，2]。目前的情况在两个方面非常不寻常。首先，肿瘤有实性和纤维性成分，没有明显的微囊。第二，与以前报道的病例不同，肿瘤虽然直径很小，但在周围组织中表现为浸润性生长，没有边界。由于肿瘤的良性性质，可以进行保守治疗，就像以前报道的病例一样。然而，外科肿瘤学家应该意识到胰腺实性SCN恶性转化的可能性，就像我们的病例一样。韩国国立癌症中心研究中心和医院，韩国庆济道410-769，高阳寺伊山路323号，电子邮件：sshan@ncc.re.kr。
A 56-year-old man visited our hospital for a pancreatic mass which was found incidentally during routine medical check-up. He had no underlying diseases and denied smoking, alcohol or familial history of malignancies. Furthermore, no symptoms or abnormalities were observed on physical examination. Laboratory tests revealed no abnormal findings. Tumor markers, including CEA and CA 19-9, were normal. An arterial-phase abdominal computed tomography (CT) scan revealed a 2.1 cm enhancing solid mass abutting the splenic vein in the tail of the pancreas (Fig. 1a, arrow). The tumor remained enhanced on a portal phase of CT (Fig. 1b). Neuroendocrine tumor of the pancreas was strongly suspected with this radiologic finding. Laparoscopic distal pancreatectomy was performed using a four-trocar incision. Gross pathology demonstrated a 2.5 9 2.0 9 1.3 cm solid mass in the pancreatic tail, which was yellow– whitish and firm, with somewhat fuzzy margins. This tumor abutted the pancreatic capsule in the upper margin (Fig. 1c). Histologic examination of the pancreas showed a solid neoplasm composed of compactly arranged glandular structures of cuboidal or polygonal cells, many of which had clear cytoplasms (Fig. 2a). A periodic acid Schiff’s (PAS) stain was weakly positive in the cytoplasm (Fig. 2b). Nuclei were evenly small and round and were darkly stained. Mitoses, cytologic atypia or papillary growth patterns were not identified. Microcystic components were rarely observed. This tumor infiltrated into the surrounding pancreas and peripancreatic soft tissue without capsule, showing frequent islet entrapment and perineural invasion (Fig. 2c). The adjacent splenic vein was invaded by the tumor (Fig. 2d). However, lymph node metastasis was not detected. Immunohistochemical staining revealed that tumor cells were positive for CK7, CK19 and MUC-6, but negative for synaptophysin. The adenomatous area was intervened by a broad band of dense fibrous stroma (Fig. 3a). The stroma showed abundant smooth muscle actin (SMA)-positive myofibroblasts (Fig. 3b). The patient is well 12 months after surgery. Since initially described in 1996, solid SCN has been known as a subtype of serous cystic neoplasms that lack secretory capability and the distinctive cystic architecture of serous cystadenoma [1]. The cytologic and immunohistochemical features of this tumor are indistinguishable from those of serous cystadenoma. All of the 11 reported cases of solid SCN exhibited a well-demarcated margin with the adjacent normal pancreas and vessels [1, 2]. The present case is very unusual in two aspects. First, the tumor has solid and fibrotic components without notable microcysts. Second, unlike the previously reported cases, the tumor shows infiltrative growth in surrounding tissue without circumscription, although it has very small diameter. Conservative treatments can be performed due to the tumor’s benign nature, as seen in previously reported cases. Nevertheless, surgical oncologists should be aware of the possibility of malignant transformation in solid SCN of the pancreas, as in our case. S. D. Lee S.-S. Han (&) E. K. Hong Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, Republic of Korea e-mail: sshan@ncc.re.kr