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Cystic pancreatic lesions

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  • 1. Imaging of Pancreatic Cystic Lesions John Murray MD, Bruce Stewart MD & Alvin Yamamoto MD NSMC Radiology Department Meeting February 4, 2009
  • 2. Outline1. BS: Overview & Approach to Cystic Pancreatic Lesions2. JM: Intraductal Papillary Mucinous Neoplasms (IPMN)3. AY: NSMC Cases
  • 3. Introduction Increasingly incidentally detected  More than 1/3 asymptomatic Imaging important for determining prognosis and management CT>MR generally preferred for characterization except for IPMN Simple classification for approach to DDx  DDx discussed here account for 90% lesions Role of Endoscopic US
  • 4. Cystic Pancreatic lesions: A SimpleImaging-based Classification System for Guiding Management Sahani DV, Kadavigere R, Saokar A, Fernandez-del Castillo C, Brugge WR, Hahn PF. Radiographics 2005 Nov-Dec;25(6):1471-84.
  • 5. Classification of Cystic Pancreatic Lesions Pseudocyst Common cystic pancreatic neoplasms  Serous cystadenoma  Mucinous cystic neoplasm  IPMN Rare cystic pancreatic neoplasms  Solid pseudopapillary tumor  Acinar cell cystadenocarcinoma  Lymphangioma  Hemangioma  Paraganglioma
  • 6. Classification of Cystic Pancreatic Lesions (cont) Solid pancreatic lesions with cystic degeneration  Pancreatic adenocarcinoma  Cystic islet cell tumor (insulinoma, glucagonoma, gastrinoma)  Metastasis  Cystic teratoma  Sarcoma True epithelial cysts* *Associated with von Hippel–Lindau disease, autosomal -dominant polycystic kidney disease, and cystic fibrosis)
  • 7. Four Morphologic Types of Cystic Lesions of the Pancreas
  • 8. Unilocular Cyst Pseudocyst IPMN occasionally Unilocular serous cystadenoma Lymphoepithelial cyst Multiple  von Hippel-Lindau  Pseudocysts
  • 9. Pseudocyst Generally symptomatic (i.e. pain)  If asymptomatic, think about another Dx History of acute or chronic pancreatitis  Almost always pseudocyst with this history Look for associated findings  Pancreatic inflammation, parenchymal calcifications, atrophy, typical intraductal calcifications Can communicate with pancreatic duct  Wide neck vs. narrow neck for IPMN Wall can calcify No mural nodules
  • 10. Pseudocyst
  • 11. Pseudocyst in a patient with a recent history of pancreatitis
  • 12. Side-branch IPMN manifesting as a unilocular cyst
  • 13. Multiple unilocular cysts in a patient with von Hippel–Lindau disease
  • 14. Microcystic Lesions Serous cystadenoma  Only lesion included in this category Benign tumor “Grandmother Lesion” May grow up to approx 4 mm/year 70% cases demonstrate:  Polycystic/microcystic pattern  Collection of cysts (>6)  Range: few mm – 2 cm  External lobulations  Enhancing septa, walls 30% demonstrate fibrous central scar +/- stellate calcifcation Other variants (macrocystic + oligocystic)
  • 15. Serous cystadenoma in 2 patients
  • 16. Serous cystadenoma(macrocystic variant)
  • 17. Macrocystic Lesions Mucinous cystic neoplasms Intraductal Papillary Mucinous Neoplasm (IPMN)
  • 18. Mucinous cystic neoplasms Mucinous cystadenomas & cystadenocarcinomas Multilocular with complex internal architecture  May contain internal hemorrhage or debris  Peripheral eggshell Ca++ predictive of malignancy  Body & tail of pancreas Asymptomatic in 75% cases  If symptoms, usually due to mass effect “Mother Lesion” High potential for malignancy Surgical resection yields good prognosis
  • 19. Mucinous cystadenomamanifesting as a multiseptated cyst
  • 20. Mucinous cystadenocarcinoma
  • 21. Mucinous cystic tumor
  • 22. Mucinous cystadenoma
  • 23. IPMNPathology: Borderline IPMN w/o in situ or invasive carcinoma Radiographics 2005; 25:1451-1470
  • 24. Endoscopic US Can provide detailed morphologic evaluation of cystic lesions  For detecting malignant tumors:  Sensitivity: 40%  Specificity: 100%  Accuracy: 50% Advantage of aspiration of contents, sampling of cyst wall, septa or mural nodule  Less potential for tumor seeding than percutaneous sampling  Highly viscous contents (mucin) consistent with mucinous neoplasm  Tumor markers, cytologic analysis, biochemical markers, fluid amylase At NSMC, performed by Drs. Jeff Oringer & Khoa Do
  • 25. Cysts with a solid component Unilocular or multilocular True cystic tumors or solid pancreatic neoplasms with cystic component/degeneration Wide DDx  Mucinous cystic neoplasms  IPMNs  Islet cell tumor  Solid pseudopapillary tumor (SPEN)  Adenocarcinoma  Metastasis All malignant or have a high malignant potential Surgical management
  • 26. Islet cell tumor manifesting as a cyst with a solid component
  • 27. Solid pseudopapillary tumormanifesting as a cyst with a solid component
  • 28. Metastases manifesting as cysts with solid components Pancreatic Adenocarcinoma Malignant IPMN
  • 29. Management
  • 30. Follow-up No consensus 6 month intervals for 1st year Annual imaging for 3 years
  • 31. Pearls  Age & Gender  “Daughter Lesion”: SPEN  “Mother Lesion”: Mucinous cystic  “Grandmother Lesion”: Serous cystadenoma  Location  Head/neck for serous & side branch IMPN  Body/tail for mucinous cystic neoplasm  Calcification  Peripheral in mucinous cystic  Central in serous cystadenoma  Mural Nodularity (enhancement = neoplasm)  Duct communication (narrow neck) favors IPMNFrom Stat Dx: Cystic Pancreatic Mass & Seminars in US, CT & MRI 2007; 28: 3389-356