Imaging of Pancreatic   Cystic Lesions   John Murray MD, Bruce Stewart MD         & Alvin Yamamoto MD      NSMC Radiology ...
Outline1.   BS: Overview & Approach to Cystic     Pancreatic Lesions2.   JM: Intraductal Papillary Mucinous     Neoplasms ...
Introduction   Increasingly incidentally detected       More than 1/3 asymptomatic Imaging important for determining  p...
Cystic Pancreatic lesions: A SimpleImaging-based Classification System for         Guiding Management       Sahani DV, Kad...
Classification of Cystic Pancreatic                  Lesions   Pseudocyst   Common cystic pancreatic neoplasms        S...
Classification of Cystic Pancreatic              Lesions (cont)   Solid pancreatic lesions with cystic degeneration     ...
Four Morphologic Types of Cystic    Lesions of the Pancreas
Unilocular Cyst Pseudocyst IPMN occasionally Unilocular serous cystadenoma Lymphoepithelial cyst Multiple     von Hi...
Pseudocyst   Generally symptomatic (i.e. pain)       If asymptomatic, think about another Dx   History of acute or chro...
Pseudocyst
Pseudocyst in a patient with a recent history of pancreatitis
Side-branch IPMN manifesting as a          unilocular cyst
Multiple unilocular cysts in a patient with       von Hippel–Lindau disease
Microcystic Lesions   Serous cystadenoma        Only lesion included in this category   Benign tumor   “Grandmother Le...
Serous cystadenoma in 2 patients
Serous cystadenoma(macrocystic variant)
Macrocystic Lesions Mucinous cystic neoplasms Intraductal Papillary Mucinous Neoplasm  (IPMN)
Mucinous cystic neoplasms   Mucinous cystadenomas & cystadenocarcinomas   Multilocular with complex internal architectur...
Mucinous cystadenomamanifesting as a multiseptated cyst
Mucinous cystadenocarcinoma
Mucinous cystic tumor
Mucinous cystadenoma
IPMNPathology: Borderline IPMN w/o in situ or invasive carcinoma                                Radiographics 2005; 25:145...
Endoscopic US   Can provide detailed morphologic evaluation of cystic    lesions       For detecting malignant tumors:  ...
Cysts with a solid component   Unilocular or multilocular   True cystic tumors or solid pancreatic neoplasms with    cys...
Islet cell tumor manifesting as a  cyst with a solid component
Solid pseudopapillary tumormanifesting as a cyst with a solid          component
Metastases manifesting as cysts with         solid components   Pancreatic Adenocarcinoma   Malignant IPMN
Management
Follow-up No consensus 6 month intervals for 1st year Annual imaging for 3 years
Pearls       Age & Gender           “Daughter Lesion”: SPEN           “Mother Lesion”: Mucinous cystic           “Gran...
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Cystic pancreatic lesions

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Cystic pancreatic lesions

  1. 1. Imaging of Pancreatic Cystic Lesions John Murray MD, Bruce Stewart MD & Alvin Yamamoto MD NSMC Radiology Department Meeting February 4, 2009
  2. 2. Outline1. BS: Overview & Approach to Cystic Pancreatic Lesions2. JM: Intraductal Papillary Mucinous Neoplasms (IPMN)3. AY: NSMC Cases
  3. 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. 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. 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. 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. 7. Four Morphologic Types of Cystic Lesions of the Pancreas
  8. 8. Unilocular Cyst Pseudocyst IPMN occasionally Unilocular serous cystadenoma Lymphoepithelial cyst Multiple  von Hippel-Lindau  Pseudocysts
  9. 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. 10. Pseudocyst
  11. 11. Pseudocyst in a patient with a recent history of pancreatitis
  12. 12. Side-branch IPMN manifesting as a unilocular cyst
  13. 13. Multiple unilocular cysts in a patient with von Hippel–Lindau disease
  14. 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. 15. Serous cystadenoma in 2 patients
  16. 16. Serous cystadenoma(macrocystic variant)
  17. 17. Macrocystic Lesions Mucinous cystic neoplasms Intraductal Papillary Mucinous Neoplasm (IPMN)
  18. 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. 19. Mucinous cystadenomamanifesting as a multiseptated cyst
  20. 20. Mucinous cystadenocarcinoma
  21. 21. Mucinous cystic tumor
  22. 22. Mucinous cystadenoma
  23. 23. IPMNPathology: Borderline IPMN w/o in situ or invasive carcinoma Radiographics 2005; 25:1451-1470
  24. 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. 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. 26. Islet cell tumor manifesting as a cyst with a solid component
  27. 27. Solid pseudopapillary tumormanifesting as a cyst with a solid component
  28. 28. Metastases manifesting as cysts with solid components Pancreatic Adenocarcinoma Malignant IPMN
  29. 29. Management
  30. 30. Follow-up No consensus 6 month intervals for 1st year Annual imaging for 3 years
  31. 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
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