Evaluation of pancreatic disease pspa 2013

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  • Many pts with pancreatic cysts are asymptomatic, and the cysts are discovered incidentally by CT for investigation of unrelated issues.When sx are present, they are often nonspecific, and may include: abdominal discomfort, wt loss, jaundice, back pain, anorexia, steatorrhea, atypical onset diabetes, anemia, pancreatitis sx... However, many of these sx raise suspicion for pancreatic CA and must be on dif dxThe major challenge in the evaluation is to identify lesions with malignant potential!
  • The differential dx of a pancreatic mass depends on whether the mass is cystic or solid.Cystic lesions include....blueThe diff dx ofr solid pancreatic mass includes a primary exocrine pancreatic cancer, a pancreatic neuroendocrine tumor (rare), metastatic cancer (rare), focal chronic pancreatitis, and autoimmune pancreatitis –uptodate.com
  • Inflammatory“Pseudocysts” and Pancreatic abcessesResult from acute or chronic pancreatitis or pancreatic traumaLack epithelial lining; often with fibrous wall and granulation tissue after 4+ weeksFairly rapid evolution sizeContains fluid (near water-attenuation) contentsPancreatic juices, necrotic debris, hemorrhage
  • Pseudocysts persisting beyond 6 weeks rarely resolved and had a complication rate of nearly 50% during continued observationBeyond 13 weeks, no further resolution was seen, and the complication rate rose sharply.Operative intervention is recommended in persisting 6 weeks to ensure that spontaneous resolution did not occur and to allow time for the wall to mature, permitting direct suturing of a cystenterostomy.
  • True cysts = benign epithelial cystsRetention cysts = small dilated pancreatic duct side branches arising due to obstruction (debri with chronic pancreatitis or cystic fibrosisMucinous NONneoplastic cysts = difficult to differentiate from PCN due to both lined w mucinous liningDifferentiate from PCN because of no atypia or ductal communicationLymphoepithelial cysts = RARE, asymptomatic. Has distinct layer of lymphoid tissue. EUS+FN bx may be required to differentiate from PCNERCP reveals rarely cyst will communicate w pancreatic duct—where 70% of pseudocysts DO HAVE ductal communication
  • 33yr study
  • Cystadenomas are classified as either:mucinous (= macrocystic adenomas)  high incidence of progression to cystadenocarcinomaSerous (=microcystic adenomas)  almost no malignant potentialDistinction is critical due to malignant potential and resection recommendationsWHO pathologic spectrum of 3 dysplastic grades:Adenoma= mucinous cystadenomaBorderline= mucinous cystic tumor-borderlineCarcinoma-in-situ = noninvasive mucinous carcinoma
  • See tx section of “Diag and tx of IPMNs of the pancreas on UptodateIPMNs may involve the main pancreatic duct, its side branches, or both.Segmental dilation of pancreatic duct without stricturingExpansion f mucin producing ductal cells with copious mucus secretionCells columnar and can be hyperplastic or dysplasticEqual sex distribution but over age of 50
  • Benign neoplasms originating from pancreatic acinar cells. Can arise anywhere in pancreas.May appear solid due to numerous septa>80% cases elderly women
  • Indolent neoplasm with rare nodal or extranodal metastasesExcellent prognosis when completely resected
  • Exocrine Pancreatic neoplasms is an inclusive term used to include all tumors that are related to the pancreatal ductal and acinar cells and their stem cells (including pancreatoblastoma)More than 95% of malignant neoplasms of pancreas arise from exocrine elements. Neoplasms arising from the endocrine pancreas (ie, pancreatic neuroendocrine [islet cell] tumors) cmprise 5% or less of pancreatic neoplasms.
  • When sx are present, they are often nonspecific, and may include: abdominal discomfort, wt loss, jaundice, back pain, anorexia, steatorrhea, atypical onset diabetes, anemia, pancreatitis sx... However, many of these sx raise suspicion for pancreatic CA and must be on dif dxThe major challenge in the evaluation is to identify lesions with malignant potential!Both symptomatic and asx pancreatic cysts require evaluation, even in pts who have had pancreatitis. (Some neoplasms can CAUSE pancreatitis), and more than half of cysts in pts with pancretitis are PCNs.
  • CT is the most common diagnostic tool used to identify pancreatic masses...whether we were looking for them or not!The typical CT appearance of an exocrine pancreatic cancer is an ill-defined, hypoattenuating mass within the pancreas.There is a “pancreas protocol” that will scan in several dynamic phases of contrast injection:Arterial enhancementpancreatic phase – looks at normal pancreas vs tumor –parenchymal aspect portal venous phase – superior mesenteric vein, portal veins, and also liver
  • Might be one of the 1st dx studies with dif dx choledocholithiasis along with other dx testing options in pts with jaundiceAlternative to ERCP in pts who have gastric outlet obstruction
  • Great for biliary-specific dx but not for a pancreatic mass that may be applying external obstruction to the biliary tract.Caution note that stent placement via ERCP may cause artifact of pancreatic head that can mask a lesion or induce inflammatory changes around stent placement indistinguishable from a tumor
  • EUS guided biopsies of a pancreatic mass can be obtained if histologic confirmation is needed, though this is not always required in pts who appear to have potentially resectable disease and have typical imaging findingsAny lesions that are visible only on EUS should be biopsied to confirm dx prior to surgical exploration. EUS FNA is best modality when inconclusive CT findings for pancreatic malignancy (87% sensitivity/ 98% specificity in study 116 pts)
  • Theoretical concern is that bx may disseminate tumor cells intraperitoneally or along the needle path in pts with potentially resectable curative resectionsIn practice, percutaneous FNA is avoided in pts with resectable masses.EUS guided FNA bx or ERCP sampling reduces these risks.
  • One report found the presence of K-ras mutation in cyst fluid to have 45% sensitivity and 96%specificity but Another report found no value Further studies are underway to validate and determine future usefullness/reliabilityMay improve sensitivity, especially in pts with small primary tumors
  • Mature pseudocysts may resolve spontaneously, often by erosion into the stomach or bowel, and do NOT require intervention except for complications = infection, hemorrhage, obstruction.Transmural drainage is suggested if the pancreatic duct is completely obstructed or if the pseudocyst is large (over 6 cm), making resolution with transpapillary drainage alone less likely. The endoscopic approach is feasible when there is close apposition between the pseudocyst and gut lumen determined by CT or MRI, or EUS.EUS guided drainage is advisable in setting of large gastric variciesOperative intervention is recommended in persisting 6 weeks to ensure that spontaneous resolution did not occur and to allow time for the wall to mature, permitting direct suturing of a cystenterostomy.
  • Pancreatic neoplasms including Endocrine and exocrine malignancy (PCNS with higher malignancy potential)Solid pseudopapillary neoplasms : Often large masses with possible metsSurgical approach either open or laparoscopic resectionPossible for curative resection with in-situMucinous cystic neoplasm/mucinous cystadenoma:Frankly malignant cysts should be surgically resected if patient is acceptable operative candidate
  • Well circumscribed, thick-walledModerate malignancy potentialPoor prognosis when invasive adenocarcinoma BUT resection can be curative
  • Most benign of PCNs. Can be watched due to low malignancy potential. Actual carcinoma is rare. Resection curative.
  • Moderate to High malignancy potentialSlow growingYoung women under 35Resection yields excellent prognosis
  • Evaluation of pancreatic disease pspa 2013

    1. 1. Evaluation of Pancreatic Disease Crystal Byerly, MEd, PA-C Seton Hill University PA Program
    2. 2. Learning Objectives • Identify the various types of pancreatic cysts and masses • Discuss the diagnostic studies used in the evaluation of pancreatic cysts and masses • Explain the treatment options of pancreatic cysts and masses
    3. 3. A PA’s common questions about the basics.... • How do we know which pancreatic cysts and masses have a bad prognosis and which are safe to “watch”??? • What diagnostic testing will give us the best information on this pancreatic abnormality?? • Which cysts and masses require treatment and which can be left alone???
    4. 4. Pancreatic cysts and masses 60+ yr old female gets CT scan for unrelated reason with incidental finding of pancreatic mass Patient presents with symptoms of abdominal pain, wt. loss, maybe vomiting or jaundice. No etiology found on EGD so CT ordered which reveals pancreatic mass Pancreatic mass on CT Patient with persistent or recurrent abdominal pain. PMH of Acute Pancreatitis, Chronic Pancreatitis, or trauma.
    5. 5. How do we know which pancreatic cysts and masses have a bad prognosis and which are safe to “watch”??? CLASSIFICATION OF PANCREATIC CYSTS AND MASSES
    6. 6. – “True” cysts of the pancreas – Neither neoplastic nor result of prior inflammation – Distinguished from other cysts only by epithelial lining – – – – – “Pseudocysts” and Pancreatic abcesses Result from acute or chronic pancreatitis or pancreatic trauma Lack epithelial lining; often with fibrous wall after 4+ weeks Fairly rapid evolution size Contains fluid (near water-attenuation) contents • Pancreatic juices, necrotic debris, hemorrhage – Benign neoplasms/ Non-neoplastic pancreatic cysts (NNPCs) • Cystic teratoma, Lymphoepithelial cysts, Serous Cystadenoma – Pancreatic cystic neoplasms (PCNs) • Malignant/Premalignant: – Mucinous cystic neoplasm, aka Mucinous cystadenoma – Solid and Papillary Epithelial Neoplasms, aka Pseudopapillary neoplasm, Intraductal papillary mucinous neoplasm
    7. 7. PSEUDOCYSTS PCNs NNPCS • IPMNs • Mucinous cystadenoma • Serous cyst tumor • Solid pseudopapillary neoplasm • True cysts • Retention cysts • Mucinous NONneoplastic cysts • Lymphoepithelial cysts PANCREATIC NEOPLASMS • Ductal Carcinoma • Acinar Cell Adenocarcinoma • Panreatoblastoma • Islet Cell tumors
    8. 8. Benign Pseudocysts • Lack of epithelial lining • is what distinguishes pseudocysts from true cystic lesions of the pancreas • No vascularized soft-tissue elements present • if vascularized elements are seen within a cystic lesion on contrastenhanced MR images, the lesion is not a pseudocyst • • • • May be single, multiple, variable in size Located inside or outside of pancreas Most communicate with pancreatic ductal system Most contain high concentrations of digestive enzymes
    9. 9. Benign Pseudocysts • Recognition of pseudocyst resulting from known inflammation (pancreatitis, trauma) makes dx more obvious • If no known inflammatory process, findings can be difficult to distinguish from the neoplastic IPMN (Intraductal papillary mucinous neoplasm) • Even mature pseudocysts may resolve spontaneously
    10. 10. Benign/Non-neoplastic Pancreatic cysts (NNPCs) • Rare • Often asymptomatic • Elderly patients with incidental CT finding even though may have been congenital etiology • Usually NO pancreatic ductal communication seen • Includes: – – – – True cysts Retention cysts Mucinous NON-neoplastic cysts Lymphoepithelial cysts
    11. 11. PSEUDOCYSTS PCNs NNCPS • IPMNs • Mucinous cystadenoma • Serous cyst tumor • Solid pseudopapillary neoplasm • True cysts • Retention cysts • Mucinous NONneoplastic cysts • Lymphoepithelial cysts PANCREATIC NEOPLASMS • Ductal Carcinoma • Acinar Cell Adenocarcinoma • Panreatoblastoma • Islet Cell tumors
    12. 12. Pancreatic cystic neoplasms (PCNs) • • • • • Females > Males 5th decade Incidental finding on CT Abdominal pain, weight loss, possibly vomiting Each of the 4 subtypes have benign and malignant forms and are categorized using the WHO histological classification: • • • • Intraductal papillary mucinous neoplasm (*38%) Mucinous cystic neoplasm/mucinous cystadenoma (*23%) Serous cystic tumor (*16%) Solid pseudopapillary neoplasm (*3%) » *Study of 851 patients underwent surgical resection for cystic lesion of pancreas between 1978-2011
    13. 13. PCN most common type: Intraductal papillary mucinous neoplasms (IPMNs) • Over 50 yrs old, F=M presentation • Mucin-producing papillary neoplasms of the pancreatic ductal system • Excellent prognosis when lesions showing only adenomatous and borderline atypia cytology • Poor prognosis when invasive carcinoma present
    14. 14. Common PCN type: Mucinous cystic neoplasm/ mucinous cystadenoma • Exclusively females > 40 • Well circumscribed masses, thick-walled, and usually unilocular (or less than 6 septa) • Like IPMNs: cellular atypia and secrete mucin • Unlike IPMNs: have ovarian-like stroma and do NOT communicate with pancreatic duct • Resection recommended due to moderate malignancy potential • Poor prognosis when invasive adenocarcinoma is present, but resection can be curative
    15. 15. PCN type: Serous cystadenomas • Most benign • Females over 60 • Imaging appearance is sponge-like or honeycomb (thin septal segments) • Unless symptomatic, can follow conservatively due to low malignancy potential • Actual carcinoma is rare, resection curative
    16. 16. PCN type: Solid pseudopapillary neoplasms • Aka solid and papillary epithelial neoplasms, solid and cystic tumors • Young women ~20’s; usually under 35 • Mixed features of solid mass with fluid and hemorrhage; necrotic debris • Well-circumscribed mass that’s slow growing • Moderate to high malignancy potential • Resection yields excellent prognosis
    17. 17. We’ve covered the benign and the questionable... Now here’s the definite bad ones
    18. 18. PSEUDOCYSTS PCNs NNCPS • IPMNs • Mucinous cystadenoma • Serous cyst tumor • Solid pseudopapillary neoplasm • True cysts • Retention cysts • Mucinous NONneoplastic cysts • Lymphoepithelial cysts PANCREATIC NEOPLASMS • Ductal Carcinoma • Acinar Cell Adenocarcinoma • Panreatoblastoma • Islet Cell tumors
    19. 19. “Pancreatic Neoplasms” • Exocrine Pancreatic Neoplasms: • Ductal adenocarcinoma (85% of all pancreatic neoplasms) • Acinar cell cystadenocarcinoma • Pancreatoblastoma • Endocrine Pancreatic Neoplasms: • Islet cell tumors
    20. 20. Ductal adenocarcinoma • • • • • Cancer Slight male predominance 60’s- 70’s VERY rare <1% Dismal prognosis
    21. 21. Acinar cell cystadenocarcinoma • • • • • • Cancer Aggressive neoplasm Males 60’s-70’s VERY rare <1% Similar to solid type Poor prognosis
    22. 22. Pancreatoblastoma • Rare pancreatic tumor with distinct acinar and squamoid cell differentiation that generally affects infants and young children • Presenting usually with abdominal mass
    23. 23. Islet Cell Tumors • Neuroendocrine • Less than 5% of pancreatic neoplasms
    24. 24. How do we know which pancreatic cysts and masses have a bad prognosis and which are safe to “watch”??? PSEUDOCYSTS PCNs NNCPS • IPMNs • Mucinous cystadenoma • Serous cyst tumor • Solid pseudopapillary neoplasm • True cysts • Retention cysts • Mucinous NONneoplastic cysts • Lymphoepithelial cysts PANCREATIC NEOPLASMS • Ductal Carcinoma • Acinar Cell Adenocarcinoma • Panreatoblastoma • Islet Cell tumors
    25. 25. What diagnostic testing will give us the best information on this pancreatic abnormality?? DIAGNOSTIC STUDIES USED IN EVALUATION OF PANCREATIC CYSTS AND MASSES
    26. 26. CT The good guy or the bad guy depending on how we look at it GOOD GUY • Initially reveals the pancreatic abnormality • Finds more pancreatic cancers than in past • Can depict small pancreatic cysts • Better demonstrates calcifications BAD GUY • Increased incidental findings lead to more tests, patient worry, professional liability concerns, higher healthcare costs • Limited evaluation of internal septa of cysts • Presence or absence of calcifications is NOT a critical diagnostic indicator in differentiation of pancreatic cysts *Preferred initial testing in pts with epigastric pain and wt loss without jaundice. *Provides local and regional disease extent, which determines resectability as well as metastatic potential. *”Pancreas Protocol CT”
    27. 27. Suspicious vs. Benign cystic features on CT • The typical CT appearance of an exocrine pancreatic cancer is an ill-defined, hypoattenuating mass within the pancreas. • If cyst is <5mm, asymptomatic, and lacks concerning features on imaging, its reasonable to repeat cross-sectional imaging in one year. • Additional evaluation (EUS) is required for most other cysts and for pts with small cysts who develop symptoms or cyst enlargement.
    28. 28. MRI • Best suited for many distinguishing features of the pancreas – Cyst morphology- clearer depiction of septa and other cyst contents (fluid, necrotic debris) – Communication with pancreatic ductal system – Good soft tissue contrast
    29. 29. BOTH CT and MRI??? • Combining CT with MRI offers little that can not be achieved by one alone. • “The choice of MRI or CT for pancreatic diagnosis depends on level of locally available expertise and the clinician’s comfort with one or the other” per UpToDate July 2013
    30. 30. MRCP • Uses MR technology to create a 3D image of the pancreatobiliary tree, liver, and vascular structures • Better than CT for biliary and pancreatic duct anatomy • At least same sensitivity to ERCP for detecting pancreatic CA • Doesn’t require contrast into ductal system like ERCP but lacks the therapeutic capability
    31. 31. ERCP • Permits visualization of biliary neoplasms while providing diagnostic and therapeutic opportunities – Collection of tissue samples by • Forcep biopsy • Brush cytology • Great for biliary-specific dx but not for a pancreatic mass that may be applying external obstruction to the biliary tract. • Sensitivity is lower than EUS-FNA for detecting pancreatic malignancy • Invasive with complication risks • Much more expensive than US or CT
    32. 32. Transabdominal Ultrasound – Commonly utilized as initial screening due to low cost and wide availability – If + for pancreatic mass, then abdominal CT typically done to confirm extent of disease • High sensitivity for detecting tumors >3cm but much lower for small tumors – A pancreatic carcinoma will appear as a focal, hypoechoic, hypovascular, solid mass with irregular margins. May also have +/- dilated bile ducts. – Lacks spacial resolution – Lack of soft tissue contrast resolution – Limited visualization in larger patients
    33. 33. EUS • Invasive ultrasound • Allows better visualization of pancreas • May be used as alternative to contrast-enhanced CT for the staging of pancreatic CA • Any lesions that are visible only on EUS should be biopsied to confirm dx prior to surgical exploration. • EUS FNA is best modality when inconclusive CT findings for pancreatic malignancy – (87% sensitivity/ 98% specificity in study 116 pts)
    34. 34. ENDOSCOPIC ULTRASOUND (EUS)
    35. 35. Pancreatic mass biopsies • EUS-guided biopsy • Not required if definite resectable mass – Is required if inconclusive CT findings for malignancy • 90% sensitivity and 96% specificity for dx of pancreatic CA • Less likely to cause peritoneal spread than percutaneous bx • Percutaneous fine needle aspiration • Pancreatic mass bx done by either US or CT guidance • ?? Possibility of intraperitoneal tumor cell dissemination???
    36. 36. Tumor Markers • CA19-9 – Used as prognostic marker and not a screening tool – Low specificity due to other cancer types and various benign pancreatobiliary disorders that would elevate – Sensitivity closely related to tumor size and of limited usefulness in small cancers • CEA level of cyst fluid (not blood test) – Best studied and most accurate tumor marker for diagnosis of a mucinous pancreatic cystic neoplasm (PCN)
    37. 37. Tumor Markers in future • Several markers are candidates in studies at this time, but none have replaced the two mentioned to date – Might be seeing more about Macrophage inhibitory cytokine-1
    38. 38. Molecular genetic analysis • Molecular markers of cyst fluid DNA has been used to differentiate PCNs from other pancreatic lesions • The addition of molecular genetic analysis are not routine component of diagnostic evaluation at present – Assay for K-ras – P53 gene mutations
    39. 39. Which cysts and masses require treatment and which can be left alone??? TREATMENT OPTIONS
    40. 40. Cystic lesion treatment • If cyst is – <5mm – asymptomatic – and lacks concerning features on imaging= textbook NNPCs • its reasonable to repeat cross-sectional imaging in one year.
    41. 41. Pseudocyst follow up • Watchful waiting recommendations vary: • Beyond 13 weeks without resolution is linked to higher complication rate – Abdominal ultrasound, CT, or MRI q 3-6m sometimes followed by conservative specialists • ERCP usually done before attempting drainage • No malignancy potential • Surgical management only if symptomatic
    42. 42. Symptomatic Pseudocyst Treatment • Intervention required for persistent, symptomatic cysts (abdominal pain or early satiety) • ERCP usually done before attempting drainage • Symptomatic tx options include: – Percutaneous catheter drainage – Endoscopic drainage (transpapillary or transmural) – Surgical drainage (cystenterostomy)
    43. 43. Principles of EUS-directed Pseudocyst Drainage Introducer Balloon dilation Pig Tail Stent •Cautery access •Wire placement •Contrast injection •Site dilation •Stent placement Barthet M, Lamblin G, Gasmi M, Vitton V, Desjeux A, Grimaud JC. Clinical usefulness of a treatment algorithm for pancreatic pseudocysts. Gastrointest Endosc. 2008 Feb;67(2):245-52.
    44. 44. Surgical resection • Pancreatic neoplasms • Solid pseudopapillary neoplasm • Mucinous cystic neoplasm/mucinous cystadenoma • Pancreatic Adenocarcinoma • If patient is a reasonable surgical candidate, and if the clinical presentation is typical for a resectable pancreatic adenocarcinoma, surgical resection is done without a preop tissue diagnosis • Complete surgical resection is only potentially curative modality for treatment of pancreatic CA • Pt is not resection candidate if there is vascular invasion, particularly of the SMA
    45. 45. Mucinous cystic neoplasm • Resection advised • Imaging suggests malignancy with descriptions such as: mural nodularity, enhancement, calcification, possible ductal obstruction,thick-walled cystic mass • Mucinous content on CT or MRI is viscous due to proteinaceous fluid • EUS w FNA yields thick mucinous fluid and elevated CEA level • DNA with mutations within the fluid accurately predicted presence of malignancy • Molecular analysis used as adjunct testing where available
    46. 46. Serous cystadenoma evaluation • Can be watched due to low malignancy potential if classic appearance • MRI > CT for septal features, and MRI better for revealing fluid content of the mass • EUS provides high-resolution imaging that highlights the sponge-like/honeycomb appearance • FNA no longer done if mass has classic appearance • Actual carcinoma is rare
    47. 47. Solid pseudopapillary neoplasms • Mixed features of solid mass with fluid, hemorrhage, necrotic debris • Often not dx until large mass (>10cm avg!!) • EUS w FNA provides accurate pre-op dx if CT/MRI questionable • Resection advised due to high malignancy potential • Possible liver metastases and lymph node involvement later in disease
    48. 48. EUS-Guided Injection of Chemotherapy • OncoGel (ReGel/Paclitaxel) • designed for intralesional injection with a sustained paclitaxel delivery over approximately 6 weeks • OncoGel was injected into 18 superficially accessible advanced solid cancerous lesions among 16 adult patients for whom no curative therapy • OncoGel injections were generally well tolerated. There was one report of grade 3 injection site pain. • stable disease was noted among 6/14 patients and progressive disease among 8 patients.
    49. 49. Cryo-Therm Ablation of the Pancreas • Flexible bipolar probe--RFA energy input (16 W) and simultaneous cryogenic cooling with carbon dioxide (650 psi) • Application time range was 120 - 900 seconds in 14 pigs • Good correlation between RFA time and size of ablation • 2/14 pigs showed histochemical pancreatitis, which was clinically overt in one. • Necropsy additionally revealed one burn to the gastric wall and four gut adhesions. • EUS – guided RFA provides pancreatic ablation Carrara S, Arcidiacono PG, Albarello L, Addis A, Enderle MD, Boemo C, Campagnol M, Ambrosi A, Doglioni C, Testoni PA. Endoscopic ultrasound-guided application of a new hybrid cryotherm probe in porcine pancreas: a preliminary study. Endoscopy. 2008 Apr;40(4):321-6.
    50. 50. A PA’s common questions about the basics.... • How do we know which pancreatic cysts and masses have a bad prognosis and which are safe to “watch”??? • What diagnostic testing will give us the best information on this pancreatic abnormality?? • Which cysts and masses require treatment and which can be left alone???
    51. 51. REFERENCES • • • • • • • • Chang KJ, Lee JG, Holcombe RF, Kuo J, Muthusamy R, Wu ML. Endoscopic ultrasound delivery of an antitumor agent to treat a case of pancreatic cancer. Nat Clin Pract Gastroenterol Hepatol. 2008 Feb; 5(2): 107-11. Federle MP, McGrath KM. Cystic Neoplasms of the Pancreas. Gastroenterol Clin N Am, 2007; 36: 365-376. Khalid, A, Brugge, Wr. ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts. Am J Gastroenterol 2007; 102:2339. Oh HC, Seo DW, Lee TY, Kim JY, Lee SS, Lee SK, Kim MH. New treatment for cystic tumors of the pancreas: EUS-guided ethanol lavage with paclitaxel injection. Gastrointest Endosc. 2008 Apr;67(4):636-42. Valsangkar NP, Morales-Oyarvide V, Thayer SP, et al. 851 resected cystic tumors of the pancreas: a 33-year experience at the Massachusetts General Hospital. Surgery 2012; 152:S4. Wang W, Shpaner A, Krishna SG, et al. Use of EUS-FNA in diagnosing pancreatic neoplasm without a definitive mass on CT. Gastrointest Endosc 2013. Yusuf TE, Matthes K, Brugge WR. EUS-guided photodynamic therapy with verteporfin for ablation of normal pancreatic tissue: a pilot study in a porcine model. Gastrointest Edosc. 2008 May; 67 (6): 957-61. Zamboni G, Kloeppel G, Hruban RH, et al. Mucinous cystic neoplasms of the pancreas. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of the Digestive System, Aaltonen LA, Hamiltion SR (Eds), IARC Press, Lyon, France 2000. p. 234.

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