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A Pancreatic Cyst Leading to Obstructive Jaundice

A 71-year-old female patient presented with new-onset jaundice (total bilirubin 7.39 mg/dL, conjugated bilirubin 5.38 mg/dL), choluria, and acholia. Her past medical history was remarkable for a pancreatic head cystic lesion diagnosed in 2009; it was a 24-mm multilocular cystic lesion, with no communication with the pancreatic duct or dilatation of this duct, with a central scar that remained asymptomatic and stable in size until 2015, when follow-up was lost. An abdominal ultrasound revealed a 47 × 45 mm heterogeneous mass in the pancreatic head, associated with de novo common bile duct (CBD) dilatation (17 mm in the liver hilum). Magnetic resonance cholangiopancreatography showed a multilocular pancreatic head cystic lesion, measuring 60 × 70 × 57 mm and apparently communicating with the main pancreatic duct (MPD), without evident central scar. There was also CBD and intrahepatic bile duct dilation, as well as pancreatic body and tail atrophy (Fig. 1). Endoscopic ultrasound (EUS) documented a predominantly microcystic lesion located in the head of the pancreas, measuring 53 × 46 mm, with a few macrocysts and pseudo-solid areas, compressing the CBD and the superior mesenteric vein, and without vascular invasion or Wirsung dilatation (Fig. 2). Fine-needle aspiration of the macrocyst and of a pseudo-solid area was performed. Cyst fluid biochemistry analysis revealed a high amylase level (54,085 UI/L) and a low CEA (2 ng/mL). EUS-fine-needle aspiration cytology showed cuboidal cells, negative for CK8/18, synaptophysin, and chromogranin-A (Fig. 3). For jaundice palliation, endoscopic retrograde cholangiopancreatography (ERCP) was then performed, and a plastic stent was placed. During ERCP, incidental pancreatic duct cannulation and contrast injection occurred, and pancreatography showed a multicystic lesion in the head of the pancreas and confirmed MPD communication (Fig. 4). At this point, differential diagnosis include sidebranch intraductal papillary mucinous neoplasm, muci-