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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