Cystic lesions of the pancreas

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  • 1. Dr. Ketul V. Shah1st year MCh G.I.Surgery resident V.S. Hospital, Ahmedabad Discussion; Dr Sanjay Nagral, Consultant GI surgeon,Mumbai.
  • 2. 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?
  • 3. 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 ++
  • 4.  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
  • 5. ON EXAMINATION pallor +, No LNpathy P/A- soft, non tender, no palpable lump, no organomegaly. No ascitis. other systems normal.
  • 6. 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
  • 7. While approaching a cystic lesionswe need to know…. Broad differential diagnosis Epidemiology of common lesions Clinical presentation Blood tests Imaging Histology
  • 8. Broad D/D’s of Cystic Pancreatic Lesions1) Pseudocyst (75-80%)2) Common cystic pancreatic neoplasms  Mucinous cystic neoplasm (10-45%)  Serous cystic neoplasm (32-39%)  IPMN (21-33%)3) Rare cystic pancreatic neoplasms  Solid pseudopapillary tumor (<10%)  Acinar cell cystadenocarcinoma (<!%)  Lymphangioma  Hemangioma  Paraganglioma
  • 9. 4) Solid pancreatic lesions with cystic degeneration  Pancreatic adenocarcinoma (<1%)  Cystic islet cell tumor (insulinoma, glucagonoma, gastrinoma) (<10%)  Metastasis  Cystic teratoma  Sarcoma5) Hydatid cyst6) Lymphatic cyst7) True epithelial cysts a/w-  von Hippel–Lindau disease  autosomal -dominant polycystic kidney disease
  • 10. Imaging in Cystic lesions…. As against Solid lesions, Imaging may be diagnostic in many cystic lesions, obviating further investigations
  • 11. Imaging in cystic lesions of pancreas;How does it help???
  • 12. Four Morphologic Types of Cystic Lesions of the Pancreas
  • 13. a) Unilocular Cyst Pseudocyst- most commonOther causes- IPMN occasionally Unilocular serous cystadenoma Lymphoepithelial cyst Multiple  von Hippel-Lindau  Pseudocysts
  • 14. b) Microcystic Lesions Serous cystadenoma(Only lesion included in this category)
  • 15. c) Macrocystic Lesions Mucinous cystic neoplasms Intraductal Papillary Mucinous Neoplasm (IPMN)
  • 16. 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
  • 17. Let us look at the possibilities inour patient……
  • 18. 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
  • 19. Blood tests in suspectedpseudocyst Amylase/Lipase
  • 20. 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
  • 21. 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
  • 22. Common neoplastic lesions and their features….
  • 23. Cystic neoplasm of pancreas
  • 24. 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.
  • 25.  Asymptomatic in 75% cases  If symptoms, usually due to mass effect  Adominal pain  Palpable mass
  • 26.  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
  • 27.  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
  • 28. Mucinous Cystadenocarcinoma Complex macrocystic lesion with internal septations Peripheral and septal calcification indicative of malignancy (arrowheads)
  • 29. 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
  • 30.  Mostly asymptomatic  being detected during evaluation for other unrelated conditions Can present with a palpable mass - size (10 to 25 cm)
  • 31. Serous Cystadenoma Lesion with numerous microcysts giving a “honey-comb” appearance Lobulated outline Central stellate scar
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. 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
  • 36. 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%)
  • 37.  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
  • 38. 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
  • 39. 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.
  • 40. Cystic lesions of Pancreas; willaspiration and analysis of fluid help?
  • 41. 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[1] Lewandrowski KB, et al. Ann Surg 1993, 217:41-7.[2] Brugge WR, et al. N Engl J Med 2004, 351:1218-26.
  • 42. Coming back to our case…
  • 43. Our patient has…. No clear cut diagnosis on history Serum markers were non-informative Imaging not diagnostic Therefore EUS guided FNA was done..……Adenocarcinoma with cystic degeneration
  • 44. DR. KETUL SHAH