Pancreatic Tumors. Presented by David Skarda, MD 04.10.23 Video
hosted by Dr. david skarda
Chapter 1 of 4 · Fundamentals
Benign lesions
Introduction and Benign Pancreatic Lesions
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Serous cystadenomas are benign lesions that may grow and become symptomatic, with rare case reports of malignant transformation, and about one-third are identified incidentally.
Serous cystadenomas are cured by removal.
Mucinous cystadenomas are more common in females and the majority are located in the tail of the pancreas.
Mucinous cystadenomas are generally considered benign but potentially pre-malignant lesions and are removed.
Mature cystic teratomas can arise anywhere within the pancreatic parenchyma and are oftentimes adjacent to the pancreas in the retroperitoneum.
Mature cystic teratomas can contain malignancy and are resected based on symptoms and malignant potential.
With the exception of serous cystadenoma which is probably totally completely benign, the mucinous versions and teratomas have enough malignant potential that biopsy may not make sense due to sampling error, and most will ultimately require resection.
In adult algorithms for small incidental pancreatic cysts less than 2 centimeters, if biopsy shows serous content, observation with surveillance is acceptable, though the appropriate surveillance duration in adolescents is uncertain.
For cystic pancreatic lesions, fluid should be sent for amylase and lipase, which theoretically should be elevated in a pseudocyst and not necessarily in neoplastic lesions.
The reason for surveillance of presumed benign pancreatic lesions may be primarily to ensure diagnostic accuracy rather than to monitor for malignant degeneration, and if a lesion is stable for 5 years in a child, annual MRI surveillance may not be necessary indefinitely.
Solid pseudopapillary tumors are the most common in young women with a mean age of diagnosis of 28 years.
Solid pseudopapillary tumors have a fairly benign course with some malignant potential, and complete surgical resection with clear margins is the treatment of choice.
Enucleation is not considered adequate treatment for solid pseudopapillary tumors, unlike insulinomas.
Overall survival with complete resection of solid pseudopapillary tumors is really good, and lymph node metastases are fairly rare.
There is a relatively high percentage (15-20%) of solid pseudopapillary tumors that present with metastatic disease, but it's called a benign tumor, and survival is still quite good without adjuvant therapy even with metastases.
In cases of solid pseudopapillary tumor with lung metastases, reported cases suggest resecting the primary tumor and letting metastatic deposits remain without requiring resection.
Pancreatoblastoma is the most common malignant pancreatic tumor in young children, with a mean age of 5 years and occurring twice as commonly in males compared to females.
Pancreatoblastomas are associated with Beckwith-Wiedemann syndrome and FAP, with some tumors having genetic abnormalities on chromosome 11p15.
In a fairly high percentage of pancreatoblastomas, alpha-fetoprotein is elevated, which can be used to monitor for recurrence after removal of the mass.
Mucinous cystadenocarcinomas are challenging to differentiate from mucinous cystadenomas, and histologically they can appear benign but frequently have foci of dysplastic or frankly malignant epithelium, making sampling a problem.
Mucinous cystadenocarcinomas are managed by complete excision, usually consisting of spleen-sparing distal pancreatectomy with adequate margins, and adjuvant chemotherapy can be considered for unresectable or metastatic disease, though efficacy is poorly understood.
Acinar cell adenocarcinomas in young children (around 3 years old) tend to be well-circumscribed masses that occur more commonly in males than females and can be equally distributed throughout the pancreas.
Acinar cell adenocarcinomas have areas of necrosis on imaging, vascular invasion is rare, and complete removal essentially results in cure without need for adjuvant chemotherapy or radiation.
Acinar cell adenocarcinomas have a much better prognosis than typical ductal adenocarcinoma.
Pancreatic ductal adenocarcinomas are extremely rare in young people and when they occur are often associated with FAP, Peutz-Jeghers syndrome, or hereditary pancreatic cancer syndrome.
Pancreatic ductal adenocarcinomas are firm, invasive tumors that frequently occur in the head of the pancreas and can cause obstructive jaundice by blocking the common bile duct.
Treatment of pancreatic ductal adenocarcinoma depends on tumor size, location, invasion, and resectability at time of diagnosis, potentially requiring palliative bypass procedures similar to adult patients.
Insulinoma is the most common pancreatic neuroendocrine tumor and is a beta islet cell neoplasm that produces excessive insulin resulting in hypoglycemia.
Insulinomas tend to be small, relatively well encapsulated, and because they make insulin, can be diagnosed fairly early.
The classic diagnostic findings for insulinoma are Whipple's triad: signs and symptoms of hypoglycemia, documented hypoglycemia during the symptomatic period, and resolution of symptoms with glucose administration.
Children with insulinomas tend to have symptoms for less than a year before diagnosis.
C-peptide levels are checked in suspected insulinoma to ensure the insulin is not exogenous (not from insulin injections).
Biochemical diagnosis of insulinoma includes elevated insulin and C-peptide levels with beta-hydroxybutyric acid level less than 2.7, with blood sugar rising after glucose administration.
Insulinomas tend to be relatively well encapsulated and surprisingly do not have blood vessels attached to them despite being endocrine tumors that secrete into the bloodstream.
Insulinomas can be enucleated and they pop out like a grape, with the main concern being the relationship of the tumor to the pancreatic duct.
Endoscopic ultrasound is really good at finding insulinomas, and intraoperative ultrasound allows visualization of the relationship of the mass to the pancreatic duct.
Sporadic insulinomas in children are often isolated and benign, while those with MEN1 tend to be multifocal and have a higher incidence of malignancy.
Gastrinomas are very rare in children and result in unregulated secretion of gastrin leading to hypergastrinemia and excessive stomach acid production with resulting ulcers in the stomach and duodenum (Zollinger-Ellison syndrome).
Eighty percent of gastrinomas occur sporadically, while 20% occur in the setting of MEN1, with MEN1-associated lesions tending to be multicentric, malignant, presenting at higher rates of metastasis and at younger ages.
About 60% of gastrinomas are not in the pancreas but are located in the wall of the duodenum, typically between where the common bile duct inserts and the junction of the second and third portion of the duodenum.
Gastrinomas can be palpated surgically, though imaging is not super great for locating them.