this is dr.dipesh from nepal .would like to share my knowledge on cystic neoplasm of pancrease

1. Dr. DIPESH K.K

2.  2nd most common exocrine pancreatic neoplasm.
 Relatively rare neoplasms
 Increased detection in asymptomatic individuals.
 2.6% of patients undergoing abdominal imaging
 1% of all pancreatic neoplasm
 10% of all cystic lesion of pancreas

3.  SEROUS CYSTIC NEOPLASM
• Serous cystadenoma
• Serous microcystic adenoma
• Serous oligocystic adenoma
• Serous cystadenocarcinoma
 MUCINOUS CYSTIC NEOPLASM
• Mucinous cystadenoma
• Mucinous cystic neoplasm with moderate dysplasia
• Mucinous cystadenocarcinoma (invasive/non-invasive)

4.  INTRADUCTAL PAPILLARY
MUCINOUS NEOPLASM
• Intraductal papillary mucinous adenoma
• Intraductal papillary mucinous neoplasm with
moderate dysplasia
• Intraductal papillary mucinous carcinoma
(invasive/non-invasive)
 SOLID PSEUDOPAPILLARY
NEOPLASM

5.  Most common types
Serous Cystic Neoplasms (SCNs)
Mucinous Cystic Neoplasm (MCNs)
Intraductal Papillary Mucinous Neoplasm
(IPMNs)
 MCNs and IPMNs are more prevalent and
have malignant potential.
 SCNs are almost always benign.

7. 
EPIDEMIOLOGY
 30% of cystic neoplasm

Female predominant F:M 4:1

Common in elderly women (60-70yrs )

TYPE

Microcystic adenoma(90%)

Oligocystic adenoma(10%)

LOCATION

Common in head of pancreas but can be evenly distributed

8.  Each cyst contains glycogen rich, clear, watery
fluid.
 Few cms to as large as 25 cms (6-10cms)
 Usually asymptomatic
 When large (>10cms) may cause symptoms
 CLINICAL FEATURES
-Epigastric mass (65%)
-Vague abdominal pain
-Features of pancreatitis(5%)
-Jaundice (10%)

9. Fluid analysis :-

Mucin stain : Negative

Amylase: Low

CEA: High
Pathological finding

Multiple small cysts Seperated by internal septation

Never communicate with pancreatic duct

Central starburst calcification

Each cyst contains glycogen rich, clear, watery fluid.
 Cysts are lined by single, uniform layer of cuboidal, glycogen
rich cells

12. 1.Ultrasound
 Nonspecific hypoechoic mass in the pancreatic
head region, possibly with internal echoes
indicating microcysts.

13. 2.CT SCAN:-

Radiating septa giving
sun burst appearance

Central calcification

15. 3.Endoscopic ultrasonography with FNA
 EUS often demonstrates a honeycomb
appearance with the microcystic variety
Cytology: Scant cellularity/Bloody
Biochemistry:
 Low CEA.
 Low amylase.
 Low CA 19-9.

16. Treatment:
 No Symptoms:
Observation 6-12 months.
 Consider resection if:
 > 4 cm.
 Symptomatic.
 No definite diagnosis.
 Rapid growth

17. 
Most common cystic neoplasm

Female predominant F:M(10:1)

Common in perimenoposal women(50-60 yrs)

LOCATION:- Mostly occurs in body and tail of
pancreas Can be evenly distributed

19.  PATHOLOGICAL FINDINGS

Unilocular or multilocular cysts Seperated by septation well
encapsulated, spherical in shape
 Content of cyst – usually mucinous, may be
haemorrhagic or watery or necrotic.
 MCNs are lined by mucin secreting columnar epithelium

20.  Subepithelial ovarian-like stroma.
Spindle cells with scant cytoplasm
Small clusters of leutinized cells.
 There is association with KRAS mutation.

21.  MALIGNANT POTENTIAL

Can be benign as well as malignant

10-15% are malignant
 Classification:
 Adenomas 75%.
 Borderline tumors
 Carcinoma.

22.  CLINICAL FEATURES

Epigastric mass (75%)

Vague abdominal pain (20%)

History of pancreatitis (20%)

Weight loss

Back pain
 FLUID ANALYSIS
Mucin stain : Positive
Amylase :Low
CEA: Low

23.  Multiple enhancing septations and solid
intramural nodules are typical radiologic
findings .
 Peripheral calcification, which can be seen in
10%–25%, is an important characteristic for
mucinous cystic neoplasms.
 can be used to differentiate them from serous cystadenomas, which are known to
have central calcification.

24. Fig.CT scan shows a complex cystic mass with a few septa in the
pancreatic tail (arrow).

25.  Figure 11. Mucinous cystadenoma.CT scan shows a large cystic
tumor with small cysts clustered at its periphery (arrow).

26. Mucinous Cystic Neoplasm Misdiagnosed as
a Pseudocyst
The fine internal septa and small intramural nodules
may not be visible at conventional contrast-enhanced
CT. This explains why mucinous cystic neoplasm
sometimes is misdiagnosed as a pseudocyst
So to avoid this better is to use multidetector CT

27.  Figure 12. Mucinous
cystadenocarcinoma in a 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.

28. Surgical resection if any of the following:
 > 3 cm.
 Main duct dilation
 Mural nodule.
 Observation if no candidate with small tumors.
Prognosis:
Poor if Invasive disease.
Follow up:
Non invasive: Annually the first years.
Invasive:
-Every 4 month the first 2 years.
-Biannually until year 5.

29.  This is a rare cystic low-grade pancreatic tumour
arising from the epithelial lining of the pancreatic
ducts.
 Excessive mucin secretion results in duct dilatation
and obstruction.
Location:
pancreatic head (58%) > body (23%) > tail (7%)
Epidemiology:-Male and female equally
Common in elderly population (60-70yrs)

30. Classified into:-
main duct type
branch duct type
and combined type.
Malignant potential :-
Can be benign as well as malignant
-25% branch duct IPMN are malignant
-75% mainduct IPMN are malignant

31. Clinical features
-Vague abdominal pain (50%)
-Features of pancreatitis (25%)
-Jaundice
-Steatorrhea and worsening of
diabetes

32.  PATHOLOGICAL FINDINGS

Poorly demarcated lobulated polycystic mass

No septation

Always communicate with pancratic duct

No calcifications

Contain micinous fluids

Mucin secreting tall columnar epithelium

With or without pappilary projections

33. 
Fluid analysis :-
-Mucin stain : Positive
-Amylase :High
-CEA:High

34.  Either segments of the pancreatic duct (or the entire
duct) are dilated and filled with low density (mucin
thus water density) material.
 Larger with prominent intraductal papillary
projections

35.  Cystic dilation of side branch of main
pancreatic duct system
 Usually in head or uncinate process
 Communicating with pancreatic ductal system

36.  Cystic mass-like appearance which often mimicks
cystic tumours of the pancreas
 Its appearance has been termed a bunch of grapes
has appearances similar to serous cystadenomas.
 But its communication with the main pancreatic duct
is the key to separate it from other lesions in the
pancreas.

37.  Risk factors of underlying malignancy
 Main Duct Disease
50 to 90% risk of carcinoma in situ and invasive
cancer
40 to 50% have invasive cancer
MPD dilation > 1cm
Mural nodules > 1cm
Risk of malignancy in branch-duct IPMNs – 25%
Risk of invasive carcinoma in branch-duct IPMNs is
even less (<15%)
 Branch-duct dilation more than 3 cm

38. CONTRAST ENHANCED CT CHARACTERISTICS:
Main pancreatic or duct dilation.
Involvement of any part of the pancreas or
the whole pancreas.
Continuity of cyst with ductal system.
Irregular and poorly demarcated

39.  Dilation of MPD and atrophy of parenchyma

40. Figure . Multiple branch
duct type of IPMT.
shows multiple cystic
masses (straight arrow).
Note the dilated pancreatic
duct (curved arrow)

41.  ERCP is regarded as the modality of choice in the
diagnosis of IPMT
Characteristic features of IPMN:
Patulous papilla resembling ‘Fish mouth’ with mucus
extruding from orifice (30%) – pathognomonic
endoscopic finding
Filling defects in dilated ducts and cystic side branches
 Triad of Ohashi
 Bulging ampulla of vater
 Mucin secretion from patulous papilla
 Dilated main pancreatic duct

42.  Pathognomonic for IPMN on ERCP – “Fish mouth
ampulla”

43.  Fig 1. Main duct ds: filling defects due to mucin globules

44. Fig.1 Branch duct ds: continuity with normal size MPD

45. MRCP
Non-invasive, diagnostic method with fewer
procedure related risks (compared to ERCP)
More specific than ERCP in imaging pancreatic
duct anatomy
Bunch of grapes appearance – Branch duct
IPMN

46.  MRCP shows both a mainduct as well as a
branchduct IPMN

47.  Intraductal Pancreatoscopy
 Main-duct intraductal papillary mucinous
neoplasm(fish-egg-like appearance).

48. Main duct IPMN

Branch duct <3cm: surveillance

Branch duct >3cm: pancreatectomy
Main duct
pancreatectomy

Partial pancreatectomy is preferred

50.  SCNs
Resection ensures cure, no surveillance or adjuvant
therapy needed
Excellent survival with 100% cure rates
 MCNs
Non-invasive MCN – do not recur after complete
resection
Invasive MCN – 5 year survival rate is 15 – 35 %
Six monthly follow up with CT/MRI for 2 years then
annually
 IPMNs
Non – invasive IPMN – 5 year survival rate >70 %
Invasive IPMN – 5 year survival rate 30 – 50 %
Yearly follow up with CT/MRI