Diagnosis And Management Of Pancreatic Cystic Lesion

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  • 1. Brief review Diagnosis and management of pancreatic cystic lesion Myoung Hwan Kim Department of Internal Medicine, Division of Gastroenterology
  • 2. pancreatic cystic lesion
    • Although the clinical, radiologic, and pathologic features of cystic pancreatic lesions are well known, preoperative diagnosis is difficult.
    • Differentiation between a pancreatic pseudocyst and a cystic pancreatic neoplasm is crucial in determining the proper treatment.
    • Recently, wide application of CT and ultrasound in asymptomatic and mildly symptomatic patients has increased detection of incidental cystic lesions of the pancreas
    •  differential diagnosis of pancreatic cystic lesions has become more challenging
    Incidental pseudocyst 77/F Serous cystadenoma 77/M Mucinous cystadenoma 38/F
  • 3. 1. Pancratic psedocyst
    • Pseudocysts are the most common cystic lesions of the pancreas(70-90%).
    • All other cystic lesions including cystic neoplasms represent only 10%–15% of pancreatic cysts.
    •  Differentiating pancreatic pseudocysts from nonpseudocysts is important for determining treatment.
    3wks after conservative Tx More 3weeks  PCD 2 month later
  • 4. 1. Pancratic psedocyst
    • Most cystic masses of the pancreas encountered in clinical practice are postinflammatory pseudocysts .
    • Pancreatic pseudocysts are defined as localized amylase-rich fluid collections located within the pancreatic tissue or adjacent to the pancreas and surrounded by a fibrous wall that does not possess an epithelial lining
      • The CT finding  a round or oval fluid collection with a thin, barely perceptible wall or thick wall that shows evidence of contrast enhancement
    • They develop most often as a complication of acute or chronic pancreatitis and may develop secondary to pancreatic trauma or surgery
  • 5. 1. Pancratic psedocyst
    • Although a prior history of pancreatitis cannot by itself justify the diagnosis of pancreatic pseudocyst, careful evaluation of the patient’s clinical history is important for the accurate diagnosis of pseudocyst.
    • Clinical scenarios
      • a pseudocyst developing after identifiable acute pancreatitis
      • a pseudocyst resulting from an acute incident superimposed on chronic pancreatitis
      • a pseudocyst with an uncertain or no known previous clinical history of pancreatitis
  • 6. 1. Pancratic psedocyst
    • Classic Postinflammatory Pancreatic Pseudocyst
    • Pancreatic Pseudocyst Superimposed on Chronic Pancreatitis
      • Pancreatic pseudocysts can occur in association with chronic pancreatitis as chronic pseudocysts  a distinct clinical history of acute pancreatitis may be lacking and the pseudocyst is often detected incidentally
      • The recognition of a pancreatic pseudocyst resulting from chronic pancreatitis is usually easy when there are associated stigmata of chronic pancreatitis such as parenchymal calcifications or ductal stones, ductal dilatation, and atrophy of the parenchyma
      • However, without these findings, pseudocysts will be very difficult to distinguish from IPMT .
  • 7. 1. Pancratic psedocyst
    • Pancreatic Pseudocyst without an Antecedent Episode of Acute Pancreatitis
      • Detection of incidental pancreatic cysts in an asymptomatic patient poses a diagnostic problem.
      • Incidental pancreatic cysts are smaller than symptomatic cysts and are unlikely to be pseudocysts
      • Cystic pancreatic neoplasm should be considered in the differential diagnosis of a pancreatic cyst, even in patients with a history of pancreatitis, if no recent episode of acute pancreatitis can be documented on clinical or imaging grounds.
      • For pancreatic pseudocysts without an antecedent episode of acute pancreatitis and radiologic evidence of pancreatitis, US-, CT-, or EUS–guided aspiration or biopsy or at least a follow-up study should be recommended.
  • 8. Treatment of pancratic psedocyst in acute pancreatitis
    • Regardless of size, an asymptomatic pseudocyst does not require treatment.
      • Abdominal ultrasonography every 3 to 6 months.
      • ERCP is usually done before attempting drainage
    • Surgical drainage of a pseudocyst
      • cyst-gastrostomy, cyst-duodenostomy, Roux-en-Y cyst-jejunostomy, pancreatic resection if the pseudocyst is in the tail.
    • Percutaneous catheter drainage
    • Endoscopic methods
      • transmural - endoscopic cyst-gastrostomy or cyst-duodenostomy,
      • transpapillary - via the p-duct and into the pseudocyst
  • 9. Treatment of pancratic psedocyst in chronic pancreatitis
    • 25% of patients with chronic pancreatitis
    • Persistent elevation in serum amylase
    • Size of the pseudocyst (6 cm) – the most important predictor of the need for intervention
    • Symptomatic, complicated, or enlarging pseudocysts - percutaneous, endoscopic, or surgical therapy
  • 10. ERCP–based algorithm for management of pancreatic pseudocysts
  • 11. 2. Pancratic cystic neoplasm
    • Cystic pancreatic neoplasms are uncommon but important because they are increasingly being detected.
    • Cystic pancreatic neoplasms are generally associated with symptoms, but an increasing number of incidental pancreatic cysts are being found.
    •  Definitive diagnosis is often possible when the lesions show typical radiologic appearances, but in many cases diagnosis by imaging alone is impossible.
    Mucinous cystadenoma 67/F Branch duct IPMN Serous cystadenoma 77/M
  • 12.  
  • 13. Differential diagnosis pseudocyst vs cystic neoplasm
  • 14. Diagnosis of cystic neoplasm (1) < Brugge WR et al. N Engl J Med 2004;351:1218-26>
  • 15. Diagnosis of cystic neoplasm (2) < Brugge WR et al. N Engl J Med 2004;351:1218-26>
  • 16. < Scheiman JM. Gastroenterology 2005;128:463-9 >
  • 17. Diagnosis of cystic neoplasm (3) < Brugge WR et al. N Engl J Med 2004;351:1218-26>
    • Tumor markers:
    • may useful in confirming the diagnosis and possibly identifying malignant change
  • 18. Algorithmic approach for the management of cystic pancreatic lesions based on the morphologic features of the lesion < Sahani DV et al. Radiographics 2005;25:1471-84>
  • 19. Algorithmic approach for the management of cystic pancreatic lesions based on the morphologic features of the lesion < Sahani DV et al. Radiographics 2005;25:1471-84>
  • 20. Mucinous Cystic Neoplasm Misdiagnosed as a Pseudocyst
    • 52-year-old woman with epigastric pain.
    • Despite the absence of a history of pancreatitis, the thin cyst wall led to the presumptive diagnosis of a pseudocyst.
    • CT scan shows a thin-walled cyst in the pancreatic tail. There is a tiny peripheral intramural nodular structure (arrow), which was initially overlooked.
    • At surgery, the lesion proved to be a mucinous cystadenocarcinoma.
  • 21. Approach to Incidental pancreatic cyst < Castillo CF et al. Arch Surg 2003;138(4):427-3>
  • 22. Approach to Incidental pancreatic cyst < Castillo CF et al. Arch Surg 2003;138(4):427-3>
  • 23. management approach for pancreatic cystic lesion. < Scheiman JM. Gastroenterology 2005;128:463-9 >
  • 24. Summary Patient with pancreatic cystic lesion Associated with acute or chronic pancreatitis ? Pseudocyst Non-pseudocyst IPMN or mucinous cystadenoma Size>5cm, symptom (+) surgery Wait & See Yes No Yes No Yes No unilocular microcyst /c solid macrocyst Wait & See Yes Serous cystadenoma Cyst aspiraton (PC, ERCP) or surgery Size>2cm, Symptom (+), yonge age Yes