Anatomy

Anatomy

Histology

Introduction

• Pancreatic cysts are sac-like pockets of fluid on or

within your pancreas

• Most pancreatic cysts aren't cancerous, and don't

cause symptoms.

• Pancreatic cysts may be detected in over 2% of

patients who undergo abdominal imaging for

unrelated reasons.

CLASSIFICATION

Pancreatic cysts

Pseudocysts Non-neoplastic

True cysts Retention cysts

Mucinous non-neoplastic cysts

Lymphoepithelial cysts

Pancreatic cystic neoplasms

Serous cystic tumors

Mucinous cystic neoplasms (MCNs)

Intraductal papillary mucinous neoplasms (IPMNs)

Solid pseudopapillary

neoplasms (SPNs)

PSEUDOCYST

• The capsule of a pseudocyst is composed of collagen

and granulation tissue and it is not lined by epithelium

• History of pancreatitis or abdominal trauma

• Cysts develop in 4-6 weeks - usually decrease in size over

time - sometimes enlarge or become infected.

• Found in any part of the pancreas or anywhere within

the abdomen and sometimes even in the chest.

PSEUDOCYST - TREATMENT

• Approximately half of all pseudocysts resolve spontaneously

• Indications for treatment include:

• infection

• large size: > 4-6 cm

• gastric outlet obstruction

• biliary obstruction

• growth on serial scanning

• Treatment options include:

• open surgical debridement, or cystenterostomy with a Roux-en-Y

jejunal loop

• endoscopic drainage into the stomach (or duodenum)

• percutaneous drainage

Serous Cystic Neoplasm

• Benign tumor, but large tumors have a tendency to increase in size and cause symptoms.

• Lobulated surface

• Can arise anywhere in the pancreas

• No communication between cysts and pancreatic duct.

• Most commonly diagnosed in women over the age 60 years

• Malignant transformation into serous cystadenocarcinoma is exceedingly rare

Mucinous Cystic Neoplasms

• Occur exclusively in women and are most

commonly discovered after the age of 40 years

• Macrocystic with thick wall septations and

peripheral calcifications (25%)

• Typically arise in the pancreatic tail or body

• Most are symptomatic, presenting with nondescript

abdominal pain

Solid Pseudopapillary Neoplasm

• Very uncommon neoplasm

• solid and cystic areas with hemorrhage on cut

sections

• seen in women 20-30 years

IPMN

In t raducta l Papi l la ry Mucinous Neoplasm

• Precancerous lesions with a well-described adenoma carcinoma sequence

• Grow within the pancreatic ducts

• May involve the main pancreatic duct, the branch ducts, or both.

• IPMNs composed of columnar tumor cells that make lots of mucin (thick fluid).

• The lesions show papillary proliferation, cyst formation, and varying degrees of cellular atypia

EPIDEMIOLOGY

• The true incidence of IPMN is not known.

• The typical age at presentation is in the fifth to

seventh decade

• male predominance in Japan and Korea

• female predominance in the United States and

Europe

• Associated with smoking

CLASSIFICATION

CLASSIFICATION

• MD-IPMNs-

• Involve the main pancreatic duct

• The majority arise within the head of the pancreas and

progress distally

• Histologically more aggressive than BD-IPMNs

• more likely to harbor a malignancy (70% in 10 years)

• BD-IPMNs-

• occur in younger patients

• arise in the uncinate process

• may also involve the tail of the pancreas.

• 20% malignancy within 10 years.

IPMN’s grading

low-grade dysplasia

(adenoma)

moderate dysplasia

(borderline)

High-grade dysplasia

(carcinoma in situ)

Invasive carcinoma

PATHOGENESIS

IPMN- COMMON MUTATIONS

• K-ras mutations:

• constitutively active MAP kinase signaling

• 50% of IPMN’s cases

• weakly associated with progression to malignancy

• CDKN2a inactivation

• SMAD4 inactivation

• ring finger protein 43 [RNF43] gene inactivation

• STK11

IPMN’s markers

• mRNAs:

• miR-21

• miR-221

• Serum antigens:

• carbohydrate antigen (CA) 19-9

• carcinoembryonic antigen (CEA)

ASSOCIATED DISEASES

• Diabetes

• Peutz-Jeghers syndrome

• familial adenomatous polyposis syndrome

• a family history of pancreatic ductal

adenocarcinoma

CLINICAL PRESENTATION

• Many patients have no symptoms

• Nausea

• Vomiting

• Abdominal pain

• Back pain

• Weight loss

• Anorexia

• Jaundice

• In most cases routine laboratory tests are normal!

DIFFERENTIAL DIAGNOSIS

• chronic obstructive pancreatitis

• mucinous cystic tumors of the pancreas

• pancreatic ductal adenocarcinoma

DIAGNOSTIC TESTS

• pancreatic protocol CT scan

• magnetic resonance cholangiopancreatography

(MRCP)

• Endoscopic ultrasound

• endoscopic retrograde

cholangiopancreatography (ERCP)

CT SCAN

MRCP

ERCP

PANCREATOSCOPY

EUS

EUS-FNA

CONCERNING RADIOGRAPHIC FEATURES:

• solid components

• pancreatic ductal dilation ≥10 mm

• lymphadenopathy

• mural nodules

• synchronous

• increase in cyst size during follow-up

SURGERY

INDICATIONS

• MD-IPMN:

• Resection recommended for all patients who are

good surgical candidates

• The main duct is ≥10 mm in diameter

• . If the duct is 5 to 9 mm in diameter, additional

evaluation (EUS with fine-needle aspiration) ) is recommended

OPTIONAL OPERETIONS

• Pancreaticoduodenectomy

• Distal pancreatectomy

• Total pancreatectomy – rare!

• Segmental resection of the tumor

PANCREATICODUODENECTOMY - WHIPPLE PROCEDURE

• The most common operation

• Contraindications:

• local vascular invasion

• distant metastases

Total pancreatectomy Distal pancreatectomy (Spleen preserving )

FOLLOW-UP AFTER SURGERY

• noninvasive IPMN – the risk of developing a recurrence in

the remaining pancreas is at least 5%. In such patients,

yearly follow-up with CT or MRCP has been suggested.

• For patients with invasive IPMN, studies suggest the risk of

recurrence is 25-50%, and it has been suggested that these patients undergo surveillance every six months.

FOLLOWING PATIENTS WHO DO NOT UNDERGO SURGERY:

• Lesions <10 mm: Evaluation every 12 months

• Lesions between 10 and 20 mm: Evaluation every

6 to 12 months

• Lesions >20 mm: Evaluation every 3 to 6 months

SURVIVAL RATES

Sohn TA, Yeo CJ, Cameron JL, et al. Intraductal Papillary Mucinous Neoplasms of the Pancreas: An Updated Experience. Annals of Surgery 2004

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