Cystic lesion of pancreas

Chan Chi KingNorth District Hospital

Ann Surg. 1893 Aug;18(2):227-8

The tumor, now the size of a small coconut , was a little above and to the left of the umbilicus, feeling like a tense cyst, & pulsating plainly form motion transmitted from the aorta. The dignosi

s of pancreatic cyst was made..

How common? Prevalence 0.21% to 24.3%

Ikeda M. et al 1994; Kimura W. et al. 1995

Size and number of pancreatic cysts increase with age Zhang. et al. 2002

? 80~90% pseudocyst ? 10% cystic neoplasm

(1% of primary pancreatic neoplasm)

Cystic lesion of pancreas

A broad spectrum of pathological entities

Distinguish pancreatic pseudocyst/ non-neoplastic cyst from pancreatic cystic neoplasm

Distinguish benign cystic neoplasm from potential malignant cystic neoplasm

Non-neoplastic lesions Pseudocyst Inflammatory pancreatic

cyst Simple epithelial cyst VHL Cystic fibrosis

Neoplastic lesions

Serous cystic neoplasm Mucinous cystic neoplasm Intraductal papillary mucinous neoplas

m (IPMN) Cystic endocrine neoplasm Solid Pseudopapillary neoplasm Ducal adenocarcinoma with cystic deg

eneration Acinar cell cystadenocarcinoma

Epidemiology

Type GenderPeak age

%

Serous cystadenoma F>M 70s 32-39

Mucinous cystic neoplasm F>M 40s 10-45

Intraductal papillary mucinous neoplasm

M=F 50s 21-33

Solid pseudopapillary neoplasm F>M 30s <10

Cystic endocrine neoplasm M=F 40s <10

Ductal adenocarcinoma with cystic degeneration

M>F 50s <1

Acinar-cell cystadenocarcinoma M>F 50s <1

Brugge WR. et al.NEJM.2004.

Presentation Found incidentally during imaging

Jaundice.. Abdominal pain..weight loss.. Anorexia..

History of pancreatitis History of alcohol abuseHistory of abdominal injury

Spinelli KS et al. Ann Surg.2004Goh BK et al. Am J Surg.2006

Frenandez-del Castilo C et al. Arch Surg.2003Allen PJ et al. J Gastrointest Surg.2003

>1/3 of Case

Symptomatic cysts are

associated with higher risk of malignancy?Cofounding with increased size

Role of CT

Characterization of pancreatic cysts

May facilitate differentiation between histological variants for larger lesions

Remain non-diagnostic for small lesions

Firm diagnosis ~ 25 -40%

Unilocular Cyst

Dushyant V. Sahani et al. RadioGraphics 2005 Massachusetts General Hospital

Marcocystic

Microcystic

Cyst with solid component

Microcystic lesion: serous cystic neoplas

m

Marcocystic lesionMucinous cystic neoplasm

Cyst with solid component IPMN

Unilocular cyst

SCN MCN IPMN

Location Even Body/tail Head

Septae Yes Yes No

Locularity Microcystic macrocystic Marcocystic

CalcificationsCentral stellat

ePeripheral curvilinear

None

Pancreatic duct

PD displaced PD displacedPD dilated &

mucin

Role of MRI

Better delineate the architecture of cystic lesion

Better delineation of pancreatic duct

Not superior to thin cut CT in making diagnosis

Role of PET scan

Italian group at Padua Sperti C et al. J Gastrointest surg. 2005

> 90% sensitivity / positive predicting value distinguish malignant from benign

Unable to distinguish pre-malignant from benign

Role of EUS

Determine type and structure of cystic lesion Facilitate fine needle aspiration Examination of pancreatic ducts and

parenchyma

morphologyaccuracy ~ 5

1%

Fine needle aspiratoncystic fluid analysis

Cytology Tumor markers

CEA, CA19-9, CA 15-3, CA 72-4 Amylase Others

ViscosityViscosityAmylaAmyla

seseCEACEA CytologyCytology EUAEUA

Serous cystic

neoplasm↓ ↓ ↓ Glycogen

microcysts

dense septations honeycomb like. central calcif

ication.

Mucinous cystic

neoplasm↑ ↔ ↑ Mucin

multiple fluid filled cavities

thin septations larger than SCN

peri. Calcification

IPMN ↑ ↑ ↔ Mucin

Dilated pancreatic duct

Connection to duct Multilocular

No septations/ calcification

Pseudocyst ↓ ↑ ↓ Histiocyte

Internal echoes representing debris Unilocular

Pancreatitis parenchymal change

Small cystic lesions ( less than 3cm)

~50% pre-malignant potential ~ 13-20% malignancy ( < 3cm)

Resect or not to resect? Surveillance? How? How Often?

EUS/ CT

Individualized decision

Retrospective study

Selection bias

Overestimate the risk

End