ERIC TRAWICK EUS CONFERENCE JUNE 2011 Pancreas Cyst

ERIC TRAWICKEUS CONFERENCE

JUNE 2011

Pancreas Cyst

Overview

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

Pancreatic cysts are being diagnosed with increasing frequency due to the widespread use of cross-sectional imaging Estimated prevalence of 1% in the general population Up to 40% are asymptomatic

Pancreatic cysts can be divided into 2 broad categories Neoplastic

Classified by the type of epithelium lining the cyst Non-neoplastic

Pseudocyst Non-neoplastic pancreatic cysts (rare)

Include retention cyst & True cysts Retention cysts Mucinous non-neoplastic cysts Lymphoepithelial cysts

Accurate cyst categorization is needed for proper management

Overview

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

• Rarely, solid pancreatic tumors may present as pancreatic cyst – Islet cell tumor

• Pancreatic cystic lesions are usually an isolated finding, but are associated with both von Hippel-Lindau disease and ADPKD– Pancreatic cyst are present in up to 70% of patients

with von Hippel-Lindau disease– Approximately 10% of patients with ADPKD have

pancreatic cyst

Cross-sectional Imaging

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

• Unreliable means of diagnosis when used alone

• Up to 40% of serous and mucinous lesions are misdiagnosed as pseudocysts

• Diagnostic accuracy of CT is reported between 20- 83%

• MRI is equivalent or slightly better than CT for diagnosis of cystic pancreatic lesions

• As expected MRCP is superior to CT in defining ductal anatomy

Journal of Computer Assisted Tomography. 1999 23(6):906-912.

Indication for EUS

World J Surg (2008) 32:2028–2037

No hard and fast rules Will EUS change management?

Symptomatic or worrisome lesions are usually resected without need for EUS &/or FNA

Is there a clear history of pancreatitis and a new cystic lesion? If obviously a pseudocyst then don’t need EUS

EUS +/- FNA is indicated to further assess and categorize cystic pancreatic lesions

EUS Morphology

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

• Cyst wall– Thick vs. thin

• Solid component• Associated with malignancy

• Septations– Micro vs. macrocystic

• Ductal abnormalities• Main duct vs. side duct

• Number of cyst• Lymphadenopathy• EUS morphology can correctly differentiate mucinous

from non-mucinous cystic lesions approximately 50% of the time

Normal Pancreas—EUS image of the normal pancreas (P, outlined by short arrows) with a finely granular echoic pattern that is characteristically very homogeneous. A part of the normal diameter (1 mm) pancreatic duct (pd) is seen in the tail. Upper pole of the kidney (K) is also visible. (Magnification range scale = 9 cm).

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

Examples of Morphology

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-309.

FNA & Fluid Analysis

Cytology High specificity, low sensitivity

Mucin High specificity, low sensitivity

Amylase/Lipase Elevated in Pseudocyst & IPMNs Low in SCN & MCN

CEA Most accurate test to distinguish mucinous from non-mucinous

cystDNA analysis

Mixed data when compared to CEA

World J Surg (2008) 32:2028–2037

Cyst Fluid Analysis

ASGE Guidelines 2005

Application

Aliment Pharmacol Ther. 2010 Jan 15;31(2):285-94

A retrospective analysis of 153 pts undergoing EUS for pancreatic cyst between 1996 to 2007

Clinical history, EUS characteristics, cytology, tumor markers and surgical histology were collected

Predictors of malignancy were determined by univariate and multivariate analysis

Application

Gastroenterology. 2004 May;126(5):1330-6

Prospective study of 341 pts found to have a pancreatic cystic lesion >10 mm on abd imaging

Exclusion criteria included: abnormal coags/platelets &/or an abscess EUS was performed looking at morphology, cyst fluid cytology, and cyst

fluid tumor markers (CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3)

Gastroenterology. 2004 May;126(5):1330-6

Summary

No single test or imaging modality can reliably differentiate cyst type

Composite data is needed Clinical features of the patient Cross-sectional imaging Tumor markers EUS with cyst fluid analysis

http://daveproject.org/pancreas-chronic-pancreatitis-with-eus-fna-of-pseudocyst/2004-05-07/

http://daveproject.org/pancreas-eusfna-of-ipmn-with-malignant-transformation/2007-11-13/ ASGE Guidelines 2005

http://daveproject.org/pancreas-serous-cyst-with-bleeding/2009-04-23/

http://daveproject.org/pancreas-serous-cystadenoma-with-fna/2007-11-13/

http://daveproject.org/eus-fna-of-solid-pseudopapillary-tumor/2011-02-21/

ASGE Guidelines 2005

GASTROENTEROLOGY 2005;128:463–469