A patient in her late 60s went to her primary-care physician with back pain, and upon further evaluation, she also noted some abdominal tenderness.

This was not the first time the patient experienced abdominal tenderness, and given the back pain, concerns for degenerative joint disease, also known as osteoarthritis, were raised.

X-rays were taken in an effort to diagnose arthritis, but the initial results were inconclusive.

During the workup, additional imaging including a CT scan and MRI was done, which confirmed osteoarthritis of the lumbar spine — a breakdown of the cartilage of the joints and discs in the neck and lower back.

However, the scans also found something else that could have contributed to her abdominal pain.


The scans revealed an incidental pancreatic cyst in the tail of the gland with some surrounding inflammation, which is known as pancreatitis.

A review of the MRI showed a simple cystic structure with no worrisome features — such as measuring more than three centimeters or having a nodule within the cystic structure.

The patient underwent an endoscopic ultrasound, a procedure where a gastrointestinal doctor places a scope down your throat and into your stomach. This allows them to see not only your stomach, but also your pancreas.

A biopsy of the cyst was done, and no cancerous cells were found. Therefore, she was put on a course of active surveillance, which consists of evaluation every six months with imaging and blood work.

Two years later, there was a subtle change noted to the cyst. It had grown to more than three centimeters, and now had some worrisome features based on imaging, including a possible nodule.

The patient underwent a repeat endoscopic procedure, and this time the area sampled confirmed cells that were suspicious for cancer. She was left with a choice: either continue surveillance, or undergo “key-hole” surgery, where surgeons remove cancerous growths with tiny cameras and incisions.

The patient chose the latter option, and underwent a successful laparoscopic distal pancreatectomy and splenectomy.

Her pathology showed a five-centimeter mass with cells that were a precursor to cancer. Whether this would have developed into an invasive cancer remains a mystery. Pancreatic cysts are often incidental findings, which is why vague abdominal pains shouldn’t be ignored. The discomfort, which was initially worrisome for joint-related pain, led to discovery of this cyst at an early stage. Because of this, the proper surveillance plan was able to be established.

The patient now returns once a year for imaging and blood work to assess the remainder of her pancreas.

Sanjay S. Reddy is an assistant professor in the department of surgical oncology at the Fox Chase Cancer Center.