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