Microcystic Adenoma Research Articles

Application of LEF-1 immunohistochemical staining in the diagnosis of solid pseudopapillary neoplasm of the pancreas

IntroductionSolid pseudopapillary neoplasm (SPN) is a tumor of young females with gain-of-function mutation in catenin beta 1 gene involved in Wnt signal transduction pathway. Beta-catenin immunohistochemistry (IHC) is used to diagnose SPN. Lymphoid enhancer-binding factor 1 (LEF-1) has been recognized in the transactivation of Wnt pathway. We aim to study LEF-1 IHC in SPN and other pancreatic tumors and compare it with beta-catenin IHC. MethodsWe retrieved cases of SPN, pancreatic neuroendocrine tumor (PanNET), serous cystadenoma (SCA), ductal adenocarcinoma (PDAC) and acinar cell carcinoma (ACC) from 2011 to 2023. Formalin-fixed, paraffin-embedded blocks with adequate tumor were cut and stained with beta-catenin (B-Catenin-1 clone) and LEF-1 (EP310 clone) IHC. Cases were reviewed by two pathologists independently. Nuclear staining with LEF-1 and beta-catenin was considered as positive. ResultsOur cohort consisted of 111 cases [SPN = 59 (42 resections, 11 FNA, 6 biopsies), PDAC = 24, PanNET = 22, SCA = 5, ACC = 1]. For SPN cases male to female ratio was1:8. Age ranged from 9 to 81 years (average: 32 years). Pancreatic tail was the most common location (47 %) followed by head (28 %), body (19 %) and neck (6 %). Tumor size ranged from 1.0 to 12.2 cm (average: 5 cm). Among the SPN cases 57/59 demonstrated strong nuclear LEF-1 staining. 2/49 cases were negative for LEF-1 (both pathologist in agreement). All SPN tumors demonstrated nuclear staining with beta-catenin. Among the non-SPN tumors, beta-catenin showed nuclear staining in 2/52 cases (2 PDAC). The remaining 50 cases were negative for nuclear beta-catenin and demonstrated variable staining pattern with interpretation variability between the two pathologists. The sensitivity and specificity for LEF-1 were 97 % and 100 %, respectively, while for beta-catenin, they were 100 % and 96 % respectively. ConclusionCrisp nuclear staining of LEF-1 without background staining makes diagnostic interpretation relatively easy and accurate compared to beta-catenin IHC. This is further helpful for small biopsy samples to help differentiate SPN from mimickers such as PanNET. None of the non-SPN cases displayed nuclear LEF-1 rendering it a valuable adjunct to beta-catenin in the diagnostic evaluation of SPN.

Imaging of pancreatic serous cystadenoma and common imitators.

Pancreatic cystic neoplasms are lesions comprised of cystic components that show different biological behaviors, epidemiology, clinical manifestations, imaging features, and malignant potential and management. Benign cystic neoplasms include serous cystic neoplasms (SCAs). Other pancreatic cystic lesions have malignant potential, such as intraductal papillary mucinous neoplasms and mucinous cystic neoplasms. SCAs can be divided into microcystic (classic appearance), honeycomb, oligocystic/macrocystic, and solid patterns based on imaging appearance. They are usually solitary but may be multiple in von Hippel-Lindau disease, which may depict disseminated involvement. The variable appearances of SCAs can mimic other types of pancreatic cystic lesions, and cross-sectional imaging plays an important role in their differential diagnosis. Endoscopic ultrasonography has helped in improving diagnostic accuracy of pancreatic cystic lesions by guiding tissue sampling (biopsy) or cyst fluid analysis. Immunohistochemistry and newer techniques such as radiomics have shown improved performance for preoperatively discriminating SCAs and their mimickers.

INSM1 is a useful neuroendocrine marker to differentiate pancreatic serous cystadenoma from pancreatic well-differentiated neuroendocrine tumors in cytology and surgical specimens

IntroductionDifferentiating pancreatic serous cystadenoma (SCA) from well-differentiated neuroendocrine tumors (WDNETs) based on histomorphology is critical yet challenging, particularly in small biopsy samples. Our study aimed to examine the expression profile of INSM1 in cytologic and surgical resection specimens from pancreatic SCA to evaluate its potential as a discriminative marker against pancreatic WDNET. MethodsWe characterized INSM1 immunohistochemistry in 34 patients with pancreatic SCA, comprising 23 surgical resections and 11 cytology specimens. As a control, we used 28 cytology specimens from pancreatic WDNET. Clinical information was retrieved through a review of electronic medical records. ResultsAll 11 pancreatic SCA cytology specimens and 15 of 23 pancreatic SCA surgical resections exhibited absent INSM1 immunostaining. Each of the remaining eight surgical resection specimens demonstrated 1 % immunoreactivity. In contrast, 27 out of 28 (96 %) pancreatic WDNET cytology specimens were positive for INSM1 immunostaining, with a median immunoreactivity of 90 % and a range of 30–90 %. Overall, INSM1 immunostains perform similarly to chromogranin and synaptophysin in pancreatic SCA. ConclusionsThe results indicate that INSM1 immunohistochemistry staining may serve as a useful neuroendocrine marker to differentiate pancreatic SCA from pancreatic WDNET in clinical practice. To our knowledge, this represents the first large-scale study to evaluate INSM1 immunostaining in surgical and cytology specimens from pancreatic SCA.

ABCD1 as a Novel Diagnostic Marker for Solid Pseudopapillary Neoplasm of the Pancreas.

The diagnosis of solid pseudopapillary neoplasm of the pancreas (SPN) can be challenging due to potential confusion with other pancreatic neoplasms, particularly pancreatic neuroendocrine tumors (NETs), using current pathological diagnostic markers. We conducted a comprehensive analysis of bulk RNA sequencing data from SPNs, NETs, and normal pancreas, followed by experimental validation. This analysis revealed an increased accumulation of peroxisomes in SPNs. Moreover, we observed significant upregulation of the peroxisome marker ABCD1 in both primary and metastatic SPN samples compared with normal pancreas and NETs. To further investigate the potential utility of ABCD1 as a diagnostic marker for SPN via immunohistochemistry staining, we conducted verification in a large-scale patient cohort with pancreatic tumors, including 127 SPN (111 primary, 16 metastatic samples), 108 NET (98 nonfunctional pancreatic neuroendocrine tumor, NF-NET, and 10 functional pancreatic neuroendocrine tumor, F-NET), 9 acinar cell carcinoma (ACC), 3 pancreatoblastoma (PB), 54 pancreatic ductal adenocarcinoma (PDAC), 20 pancreatic serous cystadenoma (SCA), 19 pancreatic mucinous cystadenoma (MCA), 12 pancreatic ductal intraepithelial neoplasia (PanIN) and 5 intraductal papillary mucinous neoplasm (IPMN) samples. Our results indicate that ABCD1 holds promise as an easily applicable diagnostic marker with exceptional efficacy (AUC=0.999, sensitivity=99.10%, specificity=100%) for differentiating SPN from NET and other pancreatic neoplasms through immunohistochemical staining.

Improving diagnostic yield of pancreatic serous cystadenoma with cyst fluid ancillary testing, adjunct immunohistochemistry, and additional fine-needle biopsy sampling.

Fine-needle aspiration (FNA) diagnosis of pancreatic serous cystadenoma (SCA) remains challenging. This retrospective study aimed to evaluate the roles of cyst fluid ancillary testing and combined fine-needle biopsy (FNB) in improving the diagnostic yield. The authors retrospectively reviewed cytology cases that were histologically confirmed SCAs. Clinical features and FNA cyst fluid biochemical and molecular analysis results along FNB findings were reviewed. The study cohort included 31 cases from 13 male and 18 female patients with a mean age of 65. The original cytologic diagnoses were nondiagnostic (n=6, 19%), negative for malignant cells/cyst contents (n=7, 23%), atypical cells (n=3, 10%), nonmucinous cyst (n=11, 35%), and serous cystadenoma (n=4, 13%). Cyst fluid carcinoembryonic antigen (CEA) analysis was performed in 17 cases, all of which showed a low CEA level (<192 ng/mL). All 14 cases with molecular testing showed a wild-type KRAS. Inhibin immunohistochemistry was retrospectively performed on the FNA cell blocks, inhibin was positive in six of seven cases tested. In 15 cases with concurrent FNA and FNB biopsies, the diagnosis of SCA was seen in only one FNA case (7%) but 13 FNB cases (87%). This study suggests that FNA diagnosis of SCA remains challenging even with ancillary testing including cyst fluid CEA level and KRAS mutation analysis. Adjunct inhibin immunostaining may help improve the cytologic diagnosis of selective SCA cases. FNB appears superior to FNA for a definite diagnosis of SCA.

Pancreatic Serous Cystadenoma: A Continuing Diagnostic Challenge.

Objective: To understand the natural history of serous cystadenoma. To understand the diagnostic accuracy of serous cystadenoma and identify possible factors that lead to the correct diagnosis. Summary Background data: Serous cystadenoma (SCA) is a benign cystic pancreatic neoplasm of the pancreas, accounting for approximately 15% of resected pancreatic cysts. Current recommendations are to proceed with surgical resection in symptomatic patients or when there is uncertainty regarding diagnosis. The latter continues to be a challenge since intentional resection of a serous cystadenoma account for only a minority of resected of cases. Methods: Retrospective single-institution review of patients who on final pathology had a diagnosis of pancreatic serous cystadenoma and of patients who had this diagnosis and were managed non-operatively. Demographic data, cyst characteristics, and growth rate were collected for analysis. Results: A total of 250 patients were analyzed. Median age was 62 (range 22 – 89), 65% were female, and 34% had symptoms. Tumor size ranged from 0.6 to 20, with a median of 3.4 cm. The morphological appearance was microcystic in 58%, macrocystic in 16%, mixed-type in 23%, and solid in 3%. Pancreatic duct dilation and pancreatic atrophy were found in 22% and 14%, respectively. The average growth rate was 1.8 mm/year regardless of tumor size. Of the 172 patients who underwent surgery, serous cystadenoma was the preoperative diagnosis in only 33%. A correct diagnosis was independently associated with large tumors and cyst fluid CEA analysis. Pancreatic duct dilation was independently associated with an in-growing cyst and presence of calcification. Conclusion: SCA is a slow-growing pancreatic cystic neoplasm that is mostly asymptomatic but can lead to pancreatic duct dilation and atrophy in some patients. A surprisingly small number of correct preoperative diagnoses confirms that this entity continues to be a diagnostic challenge. A more thorough preoperative workup that includes EUS should improve the rate of mis-diagnosis.

Resection of pancreatic serous cystadenomas: decision-making in context of modern imaging modalities

Resection of pancreatic serous cystadenomas: decision-making in context of modern imaging modalities

Перспективы диагностики и лечения панкреатической серозной цистаденомы: избежание излишнего хирургического вмешательства

Кистозные образования поджелудочной железы делят на 2 типа: воспалительные (псевдокисты) и истинные кисты, причем наиболее распространенной является воспалительная киста поджелудочной железы. Истинные кисты разделяют на 3 типа: неопластические (10–15%), застойные (10%) и врожденные (5%). Кистозные новообразования поджелудочной железы составляют 1–5% всех первичных опухолей поджелудочной железы. К ним относят серозную цистаденому. Серозная цистаденома выглядит как сферическая, заполненная жидкостью, прозрачная кистозная опухоль с четко выраженными дольчатыми краями. Чаще встречается одиночное поражение, однако может иметь место мультифокальное поражение, когда со временем множественные очаги сливаются между собой. Это характерно для пациентов с болезнью фон Хиппеля – Линдау. Серозная цистаденома имеет 3 различных морфологических варианта: микрокистозный, макро-олигокистозный и солидный. Серозные цистаденомы представляют собой однокамерные или олигокистозные поражения, которые диагностируют как кистозные опухоли. Солидный вариант может быть наиболее затруднительным для диагностики, поскольку может проявляться в виде солидного гиперваскулярного образования, которое активно увеличивается в артериальную фазу и очень похоже на нейроэндокринную опухоль поджелудочной железы. Рентгенологическая визуализация является важным инструментом для выявления серозной цистаденомы поджелудочной железы, хотя и имеет некоторые ограничения. При установленном диагнозе серозной цистаденомы небольших размеров, отсутствии симптомов, поражения протоков и сосудов консервативная терапия, несомненно, предпочтительна. Pancreatic cystic neoplasms (PCN) are divided into two types: inflammatory (pseudocysts) and genuine cysts, with an inflammatory pancreatic cyst being the most prevalent. True cysts are divided into three types: neoplastic (10–15%), congestive (10%), and congenital (5%). Cystic pancreatic neoplasms account for 1–5% of all primary pancreatic tumours. These include serous cystadenoma (SCA). Serous cystadenoma appears as a spherical, liquid-filled, clear cystic tumour with well-defined lobulated edges. They are mostly solitary lesions; however, they can have multiple lesions or multifocal and confluent neoplasms, particularly in von Hippel – Lindau patients (VHL). SCA often exhibits three different morphologic types: microcystic, macro-oligocystic, and solid. Serous cystadenomas account for 15–25% of all cases and present as unilocular or oligocystic lesions that can be diagnosed with cystic tumours. The "solid" variant could be the most perplexing and difficult to diagnose, since it might manifest as a solid hypervascular mass that actively increases on the arterial phase and seems remarkably similar to a pancreatic neuroendocrine tumour. Radiographic imaging is a powerful tool for identifying pancreatic serous cystadenoma, although it has limitations. With a clarified serous cystadenoma of small size, lack of symptoms, and no ductal or vascular engagement, conservative therapy is undoubtedly convenient.

Radiomics Based on Contrast-Enhanced Ultrasound Images for Diagnosis of Pancreatic Serous Cystadenoma.

The purpose of the study was to develop and validate a radiomics model by using contrast-enhanced ultrasound (CEUS) data for pre-operative differential diagnosis of pancreatic cystic neoplasms (PCNs), especially pancreatic serous cystadenoma (SCA). Patients with pathologically confirmed PCNs who underwent CEUS examination at Chinese PLA hospital from May 2015 to August 2022 were retrospectively collected. Radiomic features were extracted from the regions of interest, which were obtained based on CEUS images. A support vector machine algorithm was used to construct a radiomics model. Moreover, based on the CEUS image features, the CEUS and the combined models were constructed using logistic regression. The performance and clinical utility of the optimal model were evaluated by area under the receiver operating characteristic curve (AUC), sensitivity, specificity and decision curve analysis. A total of 113 patients were randomly split into the training (n=79) and test cohorts (n=34). These patients were pathologically diagnosed with SCA, mucinous cystadenoma, intraductal papillary mucinous neoplasm and solid-pseudopapillary tumor. The radiomics model achieved an AUC of 0.875 and 0.862 in the training and test cohorts, respectively. The sensitivity and specificity of the radiomics model were 81.5% and 86.5% in the training cohort and 81.8% and 91.3% in the test cohort, respectively, which were higher than or comparable with that of the CEUS model and the combined model. The radiomics model based on CEUS images had a favorable differential diagnostic performance in distinguishing SCA from other PCNs, which may be beneficial for the exploration of personalized management strategies.

Pancreatic serous cystadenoma case report of conservative approach

There are multiples pancreatic tumors, some of them being benign some being malignant, some more frequent than others, such as pancreatic pseudocyst and serous cystic neoplasm, in this case it’s about the last one witch is the most common cystic neoplasm of the pancreas about 30%, the initial approach to this type of tumors its either CT scan or MRI, which will show the honeycomb-like pattern, which is pathognomonic of this neoplasm, and the treatment options depend on the symptoms that produce.

S2028 Dramatic Improvement of Pancreatic Serous Cystadenomas 3 Months After Initiation of Belzutifan Treatment for Von Hippel-Lindau Associated Renal Cell Carcinoma

S2028 Dramatic Improvement of Pancreatic Serous Cystadenomas 3 Months After Initiation of Belzutifan Treatment for Von Hippel-Lindau Associated Renal Cell Carcinoma

Natural Evolution of Pancreatic Serous Cystadenoma on Endoscopic Ultrasound

Natural Evolution of Pancreatic Serous Cystadenoma on Endoscopic Ultrasound

Extracellular vesicle analysis of plasma allows differential diagnosis of atypical pancreatic serous cystadenoma

Increased use of cross-sectional imaging has resulted in frequent detection of incidental cystic pancreatic lesions. Serous cystadenomas (SCAs) are benign cysts that do not require surgical intervention unless symptomatic. Unfortunately, up to half of SCAs do not have typical imaging findings (“atypical SCAs”), overlap with potentially malignant precursor lesions, and thus pose a diagnostic challenge. We tested whether the analysis of circulating extracellular vesicle (EV) biomarkers using a digital EV screening technology (DEST) could enhance the discrimination of cystic pancreatic lesions and avoid unnecessary surgical intervention in these atypical SCAs. Analysis of 25 different protein biomarkers in plasma EV from 68 patients identified a putative biomarker signature of Das-1, Vimentin, Chromogranin A, and CAIX with high discriminatory power (AUC of 0.99). Analysis of plasma EV for multiplexed markers may thus be helpful in clinical decision-making.

P-248 Analyzing factors of resected pancreatic serous cystadenoma: A multicenter analysis

P-248 Analyzing factors of resected pancreatic serous cystadenoma: A multicenter analysis

Pax8 as a useful adjunct marker to differentiate pancreatic serous cystadenoma from clear cell renal cell carcinoma in both cytologic and surgical specimens

BackgroundHistomorphological differentiation between pancreatic serous cystadenoma (SCA) and clear cell renal cell carcinoma (RCC) can be challenging. We aimed to study Paired box 8 protein (Pax8) expression profile in cytologic and surgical specimens with pancreatic SCA to assess its utility as a differentiating marker from clear cell RCC.MethodsWe characterized Pax8 immunohistochemistry in 33 patients with pancreatic SCA (23 surgical resections and 10 cytology specimens). Nine cytology specimens from metastatic clear cell RCC involving pancreas were used as control tissue. Electronic medical records were reviewed to retrieve clinical information.ResultsAll 10 pancreatic SCA cytology specimens, and 16 of 23 pancreatic SCA surgical resections showed absent Pax8 immunostaining, while the remaining 7 surgical resection specimens showed 1%-2% immunoreactivities. Islet and lymphoid cells adjacent to the pancreatic SCA expressed Pax8. In contrast, the proportion of Pax8 immunoreactivity ranged from 50 to 90% (average of 76%) in nine cases of metastatic clear cell RCC involving pancreas. Using a 5% immunoreactivity cutoff, all cases of pancreatic SCA are interpreted as negative for Pax8 immunostains while all cases of metastatic clear cell RCC involving pancreas are interpreted as positive for Pax8 immunostains.ConclusionsThese results suggest that Pax8 immunohistochemistry staining can be a useful adjunct marker to differentiate pancreatic SCA from clear cell RCC in clinical practice. To the best of our knowledge, this is the first large-scale study of Pax8 immunostaining on surgical and cytology specimens with pancreatic SCA.

Retroperitoneal Cystic Lymphangioma : case report

Lymphangiomas, cystic hygroma or macrocystic lymphatic malformation are a rare and benign congential malformations of the lymphatic system. Adults are affected rarely and less than children, and the abdominal location even less. Here, we discuss the case of a 56years old woman admitted and operated for a 7cm cystic mass of the tail of the pancreas, whom per operative exploration showed a retroperitoneal polycystic mass and histopathology concluded a lymphangioma. Less than 1% affect the retroperitoneum, they typically occur in spaces surrounded by loose connective tissue, the are difficult to differentiate from a mucinous cystic neoplasm of the pancreas by imaging since both have the appearance of multilocular cysts. Ultrasonography is very sensitive and relatively specific for evaluation of abdominal cystic masses. Laparoscopic removal has certain advantages over classical laparotomy, complete excision is recommended to protect the patient from subsequent recurrences even though cystic lymphangiomas are low-grade malignancies. The diagnosis of CL often is facilitated by means of modern imaging. Differential diagnosis include pancreatic pseudocysts, mucinous and serous cystadenomas, other congenital cysts and pancreatic ductal carcinoma with cystic degeneration. If symptomatic lesions or complications arise, complete surgical excision is a must.

Endovascular treatment of haemorrhagic pancreatic serous cystadenoma

BackgroundPancreatic microcystic serous cystadenoma are rare benign pancreatic tumors. No treatment is needed in most cases as this lesion is often discovered incidentally. Surgery is not required except in symptomatic cases.Case presentationWe report herein a rare case of pancreatic serous cystadenoma complicated with a hemorrhage in a 95 years old patient treated with arterial embolization since surgery was not possible. The patient recovered without any adverse events or bleed recurrence in the 6 months following the procedure.ConclusionHemorrhage secondary to a pancreatic serous cystadenoma was successfully treated with arterial embolization, which may represent an alternative therapeutic option to surgery.

Classification prediction of pancreatic cystic neoplasms based on radiomics deep learning models

BackgroundPreoperative prediction of pancreatic cystic neoplasm (PCN) differentiation has significant value for the implementation of personalized diagnosis and treatment plans. This study aimed to build radiomics deep learning (DL) models using computed tomography (CT) data for the preoperative differential diagnosis of common cystic tumors of the pancreas.MethodsClinical and CT data of 193 patients with PCN were collected for this study. Among these patients, 99 were pathologically diagnosed with pancreatic serous cystadenoma (SCA), 55 were diagnosed with mucinous cystadenoma (MCA) and 39 were diagnosed with intraductal papillary mucinous neoplasm (IPMN). The regions of interest (ROIs) were obtained based on manual image segmentation of CT slices. The radiomics and radiomics-DL models were constructed using support vector machines (SVMs). Moreover, based on the fusion of clinical and radiological features, the best combined feature set was obtained according to the Akaike information criterion (AIC) analysis. Then the fused model was constructed using logistic regression.ResultsFor the SCA differential diagnosis, the fused model performed the best and obtained an average area under the curve (AUC) of 0.916. It had a best feature set including position, polycystic features (≥6), cystic wall calcification, pancreatic duct dilatation and radiomics-DL score. For the MCA and IPMN differential diagnosis, the fused model with AUC of 0.973 had a best feature set including age, communication with the pancreatic duct and radiomics score.ConclusionsThe radiomics, radiomics-DL and fused models based on CT images have a favorable differential diagnostic performance for SCA, MCA and IPMN. These findings may be beneficial for the exploration of individualized management strategies.

S1694 Atypical Presentation of Pancreatic Serous Cystadenoma

Introduction: Pancreatic serous cystadenomas (PSCA) which represent one-third of pancreatic cystic neoplasms are typically benign asymptomatic lesions usually found incidentally on imaging studies at the body or tail of the pancreas. When symptomatic, presents typically with abdominal pain and a palpable mass. We report a case with PSCA presented as chronic diarrhea due to pancreatic duct (PD) obstruction with further enlargement over the years leading to biliary and partial duodenal obstruction. Case Description/Methods: A 65-year-old man with chronic diarrhea and a remote history of Hodgkin’s Lymphoma treated with Mantle and pelvic radiation. Initially diagnosed as radiation enteritis, presented to our clinic with worsening diarrhea, flatulence, bloating, and weight loss. Endoscopic evaluation was negative for celiac disease or microscopic colitis. Diarrhea responded to empiric trial of pancreatic enzymes and he regained weight. CT scan of abdomen done to determine the etiology of exocrine pancreatic insufficiency (EPI) revealed a 3.7 cm complex cystic mass in the in the head of the pancreas with PD dilation and atrophy of the body and tail (Figure). Endoscopic ultrasound showed pancreatic mass with involvement of SMA and portal vein. Fine needle aspiration was not diagnostic. CT-guided biopsy was consistent with PSCA. 4 years later he complained of pale stools and dark urine; labs revealed ALT 495, alkaline phosphatase 463, bilirubin 4.5. MRI showed cyst enlargement to 5.7 cm with biliary dilation. Surgical consultation deemed him not to be a surgical candidate because of radiation induced vascular disease. ERCP with fully covered stent placement led to resolution of symptoms and normalization of liver tests. A year later ERCP with stent exchange showed compression of the duodenum distal to the stent leading to partial obstruction. Discussion: PSCA is usually an incidental finding on imaging studies. EPI is most commonly a result of chronic pancreatitis. Our patient presented with chronic diarrhea due to EPI as a result of PD obstruction by a PSCA. This case underscores the importance of imaging the pancreas in all patients with EPI to evaluate for potential underlying neoplasm causing obstruction of the PD. Our case also highlights that PSCA although benign if in the head of the pancreas can grow in size leading to gastric outlet obstruction and obstructive jaundice which can be associated with significant morbidity if the patient is not a surgical candidate.Figure 1.: There is an approximately 4.0 cm x 3.7 cm ill-defined complex mass in the head of the pancreas.

Massive pancreatic serous cystadenomas raise important questions regarding surgical management of incidental pancreatic cystic lesions: a report of two cases

The widespread use of cross-sectional imaging and ultrasound has led to an increase in the diagnosis of pancreatic cystic neoplasms. These lesions have an estimated prevalence of 2.4% of which approximately 10-16% are serous cystadenoma (SCA). SCA is the most common benign pancreatic lesion; the vast majority are asymptomatic and associated with low risk for malignant transformation. Despite improved insight into the natural history of these tumors, recommendations for their management remain contentious. We present two cases of giant SCA that call attention to shortcomings of the current guidelines for management of benign cystic pancreatic lesions. In both cases, patients presented for surgical evaluation late in the disease course despite multiple medical consultations with generalist and specialty providers. Although both lesions were resected, their late presentation may have increased risk for complication and post-operative morbidity. These cases highlight possible discrepancies between medical and surgical perspectives in the field and support future investigation into more aggressive surgical management of SCA.