Dr. Ketul V. Shah1st year MCh G.I.Surgery resident V.S. Hospital, Ahmedabad Discussion; Dr Sanjay Nagral, Consultant GI surgeon,Mumbai.
Cystic lesion in Pancreas Task aheadI. Is the lesion from pancreas?II. Lesion is solid or cystic?III. Neoplastic v/s non-neoplastic?IV. SCA v/s MCN v/s IPMN?V. Management?
CASE HISTORY 45y/F c/o recurrent vomiting and loss of appetite - 6 mths. Vomitus contained food and occurred ½ to 1 hour after meals & was non-bilious, non-projectile h/o diffuse abdominal pain significant weight loss ++ Anorexia ++
There was no preceding history of any severe abdominal pain or jaundice No h/o lump in abdomen, abdominal distension Pt is not a k/c/o diabetes and no other positive medical or surgical history
ON EXAMINATION pallor +, No LNpathy P/A- soft, non tender, no palpable lump, no organomegaly. No ascitis. other systems normal.
INVESTIGATIONS DONE LFT – wnl S. Amylase and Lipase were normal USG - A cystic lesion in the pancreatic head and neck region of about 7x5cm CECT - 73x60 mm cystic lesion in pancreatic head & neck region; cystic wall-3mm; MPD- normal; no peri-pancreatic LN or fluid. S. CA 19-9 – wnl S. CEA - wnl
While approaching a cystic lesionswe need to know…. Broad differential diagnosis Epidemiology of common lesions Clinical presentation Blood tests Imaging Histology
d) Cysts with a solid component- Unilocular or multilocular True cystic tumors or solid pancreatic neoplasms with cystic component/degeneration Solid pseudopapillary tumor (SPEN) Mucinous cystic neoplasms IPMNs Islet cell tumor Adenocarcinoma Metastasis
Let us look at the possibilities inour patient……
Could this patient have PANCREATIC PSEUDOCYST? Symptoms Abdominal pain (80 – 90%) Lump in abdomen Nausea / vomiting ( due to gastric or duodenal compression) Early satiety Bloating, indigestion Jaundice ( due to compression of bile duct) Hemorrhage Signs Tenderness Abdominal fullness Palpable mass
Blood tests in suspectedpseudocyst Amylase/Lipase
Imaging in Pseudocyst….. Ultrasonography Most practical & Sensitivity 75 – 90% limited by patient habitus, operator experience and air in stomach CT scan Gold standard for initial assessment and follow-up Sensitivity 90- 100% MRI Better detail of content of cyst MRCP Establish the relationship of the pseudocyst to the pancreatic ducts Endoscopic Ultrasonography (EUS +/- FNA) Distinguishing pancreatic cystic lesions, helps in FNA
So, if you have a cystic lesionswith….. Sudden onset of pain consistent with pancreatitis pain Imaging features of associated pancreatitis Unilocular cyst; and Elevated amylase/lipase You may not investigate any further…… It must be a pseudocyst
Common neoplastic lesions and their features….
MUCINOUS CYSTIC NEOPLASMS Most common - 10% to 45% (MCA -67%, MCAC - 33%) > 95% in women ( Mean ~ 50 yrs) Typically involve the body and tail of the pancreas Never multifocal, occurring only in one location within the pancreas.
Asymptomatic in 75% cases If symptoms, usually due to mass effect Adominal pain Palpable mass
CT or MRI of the abdomen Complex macrocystic mass with internal septations MRCP no communication between duct and the cyst Contrast enhanced scans show enhancement of the cyst wall and accentuate any septations and mural nodules Distal to the tumor, the pancreas may show changes of CP Presence of mural nodule and septal calcification s/o – malignancy
EUS can identify septations and cyst wall nodules in more detail than MRI or CT Allows cyst wall biopsy and cyst fluid aspiration for analysis Cyst fluid analysis generally reveals thick and mucoid material and low fluid amylase elevated tumor markers (CEA) mucinous epithelial cells by cytology
Mucinous Cystadenocarcinoma Complex macrocystic lesion with internal septations Peripheral and septal calcification indicative of malignancy (arrowheads)
SEROUS CYSTADENOMAS Second MC Cystic tumor of the pancreas formerly known as microcystic adenomas Occurring mostly in women (75%) with a mean 62 years Most (50% to 70%) occur in the body or tail of the pancreas An association with von Hippel-Lindau disease
Mostly asymptomatic being detected during evaluation for other unrelated conditions Can present with a palpable mass - size (10 to 25 cm)
Serous Cystadenoma Lesion with numerous microcysts giving a “honey-comb” appearance Lobulated outline Central stellate scar
Serous cystadenoma Pathognomonic image by CT scan is that of a spongy mass with a central “sunburst” calcification - only 10% of patients Visualization of four of the following five CT and MRI features aid in making the diagnosis location in the pancreatic body and tail wall thickness < 2 mm lobulated contour lack of communication with the pancreatic duct minimal wall enhancement
IPMN(Intra-ductal Papillary Mucinous Neoplasm) Types - depend on involvement of duct main pancreatic duct, isolated side branches, or a combination of both Benign (adenoma), borderline, or malignant Malignant neoplasms account for 60% of IPMNs
IPMN FEATURES Equal frequency in men and women Median age at diagnosis - about 65 years 75% of patients are symptomatic Abdominal pain and weight loss – MC complaints Recurrent pancreatitis or Acute pancreatitis Patients with malignant neoplasms are more likely to be older and more likely to present with jaundice or new-onset diabetes
DIAGNOSIS Differentiation of IPMN from other cystic pancreatic masses may be difficult at CT Most reliable findings for the diagnosis Presence of a communication between the cystic lesion and the main pancreatic duct Presence of mural nodules projecting into the main pancreatic duct or cystic lesions
DIAGNOSIS Diffusely distended pancreatic duct with mucinous filling defects and grape-like, cystic, space-occupying lesions Sensitivity in diagnosing an IPMN highest for MRI with MRCP (88%),followed by ERCP (68%) and CT (42%)
Pathognomonic for IPMN in ERCP A wide and gaping papilla with secretion of mucin and filling defects in the dilated pancreatic duct –FISH MOUTH AMPULLA
Cystic lesions of pancreas; will blood tests help ? Amylase and/or Lipase?? CEA? Ca 19-9 ??Not diagnostic of any of the cystic pancreatic tumorsOnly provide corroborative evidence
Serum amylase or lipase levels Increased - pseudocyst, IPMNSerum CA 19-9 & CEA normal - benign cystic pancreatic tumors modestly elevated - MCNs and IPMNs, particularly patients with malignancies Markedly elevated -retention cyst secondary to obstruction of the main pancreatic duct by an adenocarcinoma.
Cystic lesions of Pancreas; willaspiration and analysis of fluid help?
Cyst Fluid Analysis Viscosity Amylase Cytology Pseudocyst Low High Inflamm. SCA Low Low 5% + MCA High Low 40% + MCAC High Low 67% + CEA CA 15-3 CA 72-4 Pseudocyst Low Low Low SCA Low Low Low MCA High High Low MCAC High High High Lewandrowski KB, et al. Ann Surg 1993, 217:41-7. Brugge WR, et al. N Engl J Med 2004, 351:1218-26.