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Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
Git j club panc cysts.
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Git j club panc cysts.

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  • 1. LOGO Prepared by: Dr.Mohamed Shekhani
  • 2. Summary:  Pancreatic cysts are challenging to the gastroenterologist.  Detection rate is increasing.  No criteria for a definitive diagnosis& no validated surveillance strategy.  Pancreatic endosonography with or without sampling is necessary in most of the cases, although this requires expertise & not widely available.  While some cysts have a malignant potential or already malign at the diagnosis, most are benign& remain so for decades. www.themegallery.com
  • 3. The problem:  Prevalence is 1% in <40-10% in > 70 - 27.5-50% in autopsy.  Pancreatic cystic neoplasms (PCNs) account for 10-15% of all cystic lesions& 1-5% of all primary pan neoplasms.  Increased prevalence is a reflection of increased diagnosis.  No gender difference, however cystic neoplasms are more common in women: 2-3:1.  MRI is more sensitive (incidental detection 20%) in detection than CT.  TAUS the least &EUS is most sensitive + easy sampling.
  • 4. Etiology:  No solid data.  Pancreatic ductal adenocarcinoma (PDAC)& colloid carcinoma may develop in mucinous cystic neoplasm MCN & IPMN.  Pancreatic intraepithelial neoplasia (PanIN) is considered a precursor of ductal adenoca& there are some genetic alterations in IPMN & PanIN & some in PDAC.  ? Whether these genetic alterations are responsible for development or progression& transformation, but likely.  MCN is composed of papillary cells producing mucin with a supporting ovarian-like stroma which suggests development from heterotopic embryonic islets of ovary left in pancreas.
  • 5. CLINICAL PRESENTATION:  >70% of the cystic lesions discovered incidentally.  In pseudocysts, even asymptomatic H/O pancreatitis is elicited in most of the time.  In incidental cysts at operation, 28% were mucinous cysts, 27 % IPMN, 17% SCN, 3.8% were pseudocysts&2.5% were ductal adenocarcinoma.  H/O pancreatitis does not validate pseudocyst, because IPMN causes acute recurrent pancreatitis.  Any type of pancreatic lesion including PDAC may first present with an acute attack of pancreatitis as the result of obstruction of MPD.  In cystic neoplasm >9 cm, it may cause pain due to the pressure to the adjacent organs.
  • 6. CLINICAL PRESENTATION:  Pancreatic cystic neoplasms, usually, displace, not invade the adjacent organs, so CBD obst is rare in PCNs of the head of pancreas.  Asking for the presence of symptoms is an important, because symptoms mandate a surgical resection even in the benign lesions like SCN.  Some endocrine neoplasms like insulinoma may appear as cystic lesion &symptoms of this particular neoplasm like hypoglycemia may be present.
  • 7. Lab exam:  Does not help much except direct exam of cyst fluid obtained with EUS-FNA.  Even EUS-FNAis not perfect, because fluid may not be obtained or the markers like CEA& amylase are either not enough sensitive or specific.
  • 8. Imagings:  PCNs almost always referred to gastroenterologists, after being discovered in an imaging modality.  May be discovered by a careful EUS done for other reasons.  MRI is more sensitive.  MDCT may be better for characterization.  MRCP is used for the evaluation of duct connection.  PET-CT is controversial ? for the assessment of malignant transformation.
  • 9. Imagings:EUS  Cross-sectional imaging changed the detection, while EUS changed the management.  Pancreas was difficult to approach before EUS.  EUS provides access to all parts of pancreas either trans- gastrically or duodenally.  Cysts can be detected, characterized, sampled; fluid is aspirated in case there is enough volume.  Pseudocyts are drained.  Some investigational treatments are delivered via EUS.  For pancreatic exam usually, if not always, use linear device.  For the exam of possible very small lesions, if failed to find a lesion with linear EUS, radial used.
  • 10. Imagings:EUS  The rate of accurate diagnosis based on EUS morphology alone, is 40- 93% depending on the experience.  in Western, EUS-guided puncture of cysts is frequently performed, in Japan, if mucinous lesion suspected it is avoided .  The predictive value of EUS-FNA in deciding for surgery reported to be as high as 95%.  The cytologic yield of EUS-FNA is rather poor:50%  The rate of sufficient material is 49 % for fluid analysis, 31% for cytology,may be increased with some special techniques as puncturing the wall at the expense of increased risk of pancreatitis.
  • 11. Imagings:EUS  If atypical cells is considered as the diagnostic criteria for malignancy the accuracy increases to 85%.  The differential diagnosis of EUS is challenging & effective use of EUS may prevent unnecessary surgery.  Even in a tertiary hospital, 20% of resected PCNs were found benign.  Without EUS, the imaging diagnosis of pancreatic cysts is not accurate enough because of the overlapping features.  Whether EUS-FNA carries a higher risk of infection is controversial ? Antibiotic use .  The risk of pancreatitis is overall 0-2% increased with pancreatic duct puncture,mostly, mild.  Severe bleeding is also very rare & mostly intracystic.
  • 12. PSEUDOCYSTS  2/3 of all pancreatic cysts.  In incidentally discovered cysts, pseudocyts is second to cystic pancreatic neoplasms.  Pseudocyts are unilocular & usually >30 mm.  They contain floating debris &found in any part of panc.  Aspiration with 22 G &even 25 G needle yield fluid.  The aspirated fluid is, muddy-brown,but may be clear or white turbid& not contain mucus.  In some aspiration may not be possible, because of thick fluid, which requires the use of 19 G needle.  The amylase content is over 2000 U/L (usually tens of thousands) & CEA level is very low or undetectable.
  • 13. PSEUDOCYSTS  A rare entity pseudopseudocyst characterized by inflammatory exudative fluid collection.  If > 60 mm&symptomatic, endoscopic drainage is required.  Drainage is postponed until 8 weeks after an acute pancreatitis to allow time for maturation of the wall.  If the cyst does not resolve until 24 weeks, it is unlikely that it would resolve later.  For drainage always an EUS-guided approach used, even if there is bulging to the stomach or duodenum.  For drainage form stomach, try to position the therapeutic linear endoscope tip in the below position: First we try to achieve a straight position to ease the insertion of needle, second we try to find a place from which the cyst is close to the stomach wall& try to achieve a vessel-free area.
  • 14. PSEUDOCYSTS  We either prone position with deep sedation, or supine position with general anesthesia.  Usually insert a fully covered, or more recently, a specifically designed cysto-gastrostomy metallic stent .  Usually perform the procedure under x-ray guidance, however it is not an absolute necessity.
  • 15. www.themegallery.com
  • 16. SEROUS CYSTIC NEOPLASM(SCN)  1-2% of pancreatic neoplasms& 25% of all cystic tumours usually, diagnosed on imaging.  A microcystic thin walled septa which are vascular, a central scar (in 30% in CT), calcifications,a poorly developed capsule difficult to distinguish form the surrounding parenchyma, confirm the diagnosis in elderly.  The classical honeycomb pattern is present in 20%.  In some cases the lesion is oligocystic confused with IPMN  Most <15 cm are asymptomatic& if the radiologic findings are conclusive, there is no absolute need for EUS exam.  In 50%, it is possible to aspirate fluid for CEA that excludes a mucinous tumour.  In the remainder result with the aspiration of blood which is an indirect clue for SCN.
  • 17. SEROUS CYSTIC NEOPLASM(SCN)  The aspirate stains negative for mucin.  The acquired cells have glycogen-rich clear neoplasm that stains positive with PAS.  Unilocular variant of SCN, usually, localized in the head.  In some cases of SCN the lesion may obstruct the MPD&it may be dilated, sometimes mimicking main duct-IPMN.  SCN is a benign neoplasm &malignant transformation risk is virtually non-existent.  It is slowly growing& most of the afflicted patients are elderlies with comorbidities.  The decision for resection should be cautious, unless there are clear-cut signs of compression symptoms which are not frequent.  The growth rate is usually 0.6 cm/year->2 cm/year if>4 cms.
  • 18. www.themegallery.com
  • 19. www.themegallery.com
  • 20. Mucinous cystic neoplasm (MCN)  2% of all pancreatic neoplasms ,1/3 of all cystic neoplasms.  Mostly a cystic neoplasm of women (female: male 20:1) usually at the perimenapousal age, average age 48.  MCN, is consisted of papillary mucin secreting cells supported by fibrous ovarian type of stroma.  Female hormones have a certain role in the progression.  Mostly, located either in body or tail &peripheric location.  In most of the MCNs,MR & MRCP makes correct diagnosis.  MRCP is very effective in demonstrating communication between cyst &pancreatic duct & its absence is a suggestive features of mucinous cyst & usually diagnostic.  Lack of communication with the main pancreatic duct is a controversial issue at the moment, because, amylase is, sometimes, elevated indicating small communications.
  • 21. Mucinous cystic neoplasm (MCN)  MCN is considered to have a malignant potential.  Malignant transformation happens, at the most 15% (8- 29- 36%) &the risk is very low in cysts with a diameter <30 mm without mural nodules.  Aspirated fluid, reveals high CEA (> 200 ng/mL),rarely may be low.  Malignant MCNs have peripheral calcification, a thickened wall, papillary proliferations & a hypervascular pattern &may show vascular involvem.  Pure colloid carcinoma as it is in IPMN is rare in MCN.  The decision for resection discussed with the patient.  Given to the fact that these patients are relatively young, &the tumor location generally allows distal pancreatectomy, the trend is for surgical resection.
  • 22. Mucinous cystic neoplasm (MCN)  If no malignancy in resected specimen, follow-up is not necessary.  if malignancy is present, there is a high risk of recurrence, & should be followed-up 6 monthly with CT or MRI.  While 5 survival rate for the resection of benign MCN is 95%, it is 50-60% for malign MCN.
  • 23. www.themegallery.com
  • 24. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  Is a mysterious disease recently known (30 years only).  Increasingly diagnosis &high risk of malignant transform.  It is diagnosed mostly >60, but may be younger.  It does not show gender predilection.  Histologically, 5 types: 1- Gastric foveolar 2- Intestinal 3- Pancreato-biliary 4- Oncocytic 5- Tubular.  Gastric foveolar type is usually benign, cystadenocarcinoma may develop in intestinal&ductal adenocarcinoma & pancreato-biliary type.  IPMN is usually diagnosed with CT, MR, MRCP.  The final diagnosis,is with EUS.  Are unilocular or macrocystic& fluid is obtained with FNA in most of the cases.
  • 25. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  If fluid is highly viscous, aspiration may not be possible  If even a drop of fluid is obtained, tenacious nature points toward a mucinous cyst.  If a drop of fluid is hold between the thumb & index finger &stretched apart, a string is formed in mucinous cyts.  If CEA is >200 ng/mL, it is almost certainly a mucinous cyst, but lower levels do not exclude diagnosis.  Enough fluid, needs at least 15 mm cyst for CEA measure.  The cyst fluid amylase is elevated even if it is not as high as it is in pseudocysts.  The significance of cyst fluid amylase for DD was challenged, because it may be found to be elevated in cysts without any communication with the pancreatic duct.
  • 26. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  in < 1/3 of IPMN, the diagnosis may not be certain.  The decreasing amylase, rather than increasing CEA may point towards a malignant transformation, because proliferation of tissue obstructs the communication between the cyst & the duct.  In BD-IPMN, if the cyst size is < 30 mm, the MPD diameter is <6 mm& mural nodules are absent, the malignancy risk is very low.  Mural nodules are internal projections of papillary tissue.  While in the past mural nodules are, uniformly, considered as an ominous sign, in recent years, it appeared that in < 1/3, the mural nodules in EUS are not associated with malignancy&the height of the mural nodules come into consideration.
  • 27. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  The malignancy risk is high in type III or IV mural Nodules.  the mean diameter of mural nodules was 5.1 mm in benign lesions & 20.5 mm in malign lesions.  In EUS the rate of describing the mucus as an intracystic lesion reaches 65%.  While EUS is more sensitive (75% vs. 24%), CT is more specific (100% vs. 83%) in diagnosing mural nodules .  In BD-IPMN, the overall risk of malignancy is around 25% (8- 29-36%).  Cytological yield is poor with EUS-FNA: Cytology was positive in only 29% of malignant mucinous tumours. However the specificity is quite high, 83% .  The rate of sufficient material obtained by EUS-FNA was reported as 31% for cytology&49% for fluid analysis.
  • 28. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  In MD-IPMN, MPD appears, hugely dilated (usually >10 mm) filled with echogenic material (mucin).  In endoscopy, mucin protruding form papilla vateri is observed: “fishmouth” sign.  While malignancy is found in 58-92% of main duct tumours, the rate is 6-46% in branch duct IPMN.  As the age increases, the rate of malignancy increases  Many malign mucinous neoplasms have peripheral calcification, a thickened cyst wall, papillary proliferations& hypervascular pattern&sometimes, vascular involvement.
  • 29. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  Another variant of IPMN involves both BD/MPD called as Mixed-type-IPMN.  In mixed as well as MD IPMN, it is very difficult to discern up to which level the tumour extends&serial in-theatre, resection margin pathology is needed, to decide to stop or go on with further resection (creeping pancreatectomy).  In some cases of IPMN, some part of inner wall may be denuded&pathologically be confused with pseudocyst.  Very recently, non-neoplastic variant of IPMN was described (Mucinous non-neoplastic cyst, MNNC),usually unilocular & localizes in the head of the pancreas,has mucinous content,not neoplastic, the CEA level is low& the risk of malignant transformation, virtually, does not exist.
  • 30. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  In BD-IPMN, surgery is advised for symptomatic patients with cysts of any size, >30 mm., or with features suggesting malignancy.  After resection, 6 monthly follow- up is necessary.  For asymptomatic patients with <10 mm BD-IPMN yearly cross-sectional imaging suffices, for 10 -20 mm,6 monthly.  For cysts between 20-30 mm, 3-6 monthly follow-up preferably with EUS.  Patients with IPMN also necessitates a surveillance for other synchronous extra-pancreatic malignancies.  In a series including surgically resected BD-IPMN, the rate of malignancy was <10% in cysts <2 cm without mural nodules, 24% in cysts 2-3 cm in size regardless of nodularity& 44% for cysts >3 cm with mural nodules.
  • 31. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  Overall increase in size of the cyst 5 mm. or more may be considered an indication for surgery outside of consensus- guidelines indicated resection.  However the size alone is not a decision making variable, in case the size is 3 cm or below.  CT findings are helpful in the evaluation of complex cystic structures.  In asymptomatic patients with pancreatic cysts < 3 cm, the frequency of occult malignancy was found 3.3%, whereas 90% of patients with malignant lesions were symptomatic.  Recently IPMN was considered as a diffuse pancreatic pre- malign or malign condition, because the risk of concurrent PanIN &another IPMN are increased (21% to 41%)
  • 32. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)  The same studies showed, in case there are multiple IPMNs in pancreas, the risk of malignancy is lower.  Another interesting observation is the increased risk of synchronous or metachronous primary extrapancreatic tumours, such as cancers of stomach, colon, rectum, lung, breast or liver in patients with IPMN.  In an analysis of 183 resected invasive IPMNs, 66% were classified as PDAC derived from IPMN & 17% as PDAC concomitant with IPMN (62).  The five year survival is 57% in colloid & 16% in tubular carcinoma.
  • 33. www.themegallery.com
  • 34. www.themegallery.com
  • 35. www.themegallery.com
  • 36. LOGO Click to edit subtitle style

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