Presented on 9th Chaitra,2077 in Gastrosurgery Department

1. Approach to cystic lesion of
Pancreas
Dr. Kiran Pandey
MS Gen. Surgery Resident,
Bir Hospital, NAMS

2. Approach
 Is the lesion from pancreas?
 Lesion is solid or cystic?
 Neoplastic v/snon-neoplastic?
 SCAv/s MCN v/sIPMN?
 Management?

3. Case
27 years male
c/o earlySatiety,Recurrent vomiting and loss of appetite -3 to
4 months.
Vomitus contained food
 occurred ½ to 1hour after meals
 Non-bilious,non-projectile
h/o diffuse abdominal pain for 4 weeks
significant weight loss++
Anorexia ++

4. Preceding h/o severe abdominal pain
multiple episodes,
consumption of alcohol
H/o abdominal distension
 History of similar pain in the past over last 2 years .
No other medical or surgical history

5. On examination
Pallor: present
P/A- soft, mild tender, distended, palpable lump, no
organomegaly,
Other systems :normal.

6. Investigation
 LFT – WNL
 S. Amylase and Lipase were normal
 USG
A cystic lesion in the lesser sac about 14x15cm
 CECT – 15x 17 cm well-circumscribed, oval pancreatic bed fluid collections
of homogeneously low attenuation,
surrounded by a well-defined enhancing wall adherant to posterior wall of
stomach and compressing stomach cavity.
cystic wall-3mm; MPD- normal; retroperitoneal lymphnode is enlarged.
 S. CA 19-9 – 1.4 ng/ml
 S. CEA – 2.3 ng/ml

8. Must know
 Broad differential diagnosis
 Epidemiology of common lesions
 Clinical presentation
 Blood tests
 Imaging
 Histology

9. Differential Diagnosis
 Pseudocyst (75-80%)
 Common cystic pancreatic neoplasms
Mucinous cystic neoplasm (10-45%)
Serous cystic neoplasm (32-39%)
 IPMN (21-33%)

10.  Rare cystic pancreatic neoplasms
 Solid pseudopapillary tumor (<10%)
 Acinar cell cystadenocarcinoma (<1%)
 Lymphangioma
 Hemangioma
 Paraganglioma

11.  Solid pancreatic lesions with cystic degeneration
 Pancreatic adenocarcinoma (<1%)
 Neuroendocrine tumours
(insulinoma, glucagonoma, gastrinoma) (<10%)
 Metastasis
 Cystic teratoma
 Sarcoma

12.  Hydatid cyst
 Lymphatic cyst
 True epithelial cysts a/w-
von Hippel–Lindau disease
autosomal -dominant polycystic kidney disease

13. Imagingin Cystic lesions….
Imaging may be diagnostic, obviating further investigations

14. FourMorphologic Typesof Cystic Lesionsof
thePancreas

15. Unilocular Cyst
Pseudocyst- most common
Other causes-
IPMN occasionally
Unilocular serous cystadenoma
Lymphoepithelial cyst
Multiple
 von Hippel-Lindau
 Pseudocysts

16. Microcystic Lesions
Serous cystadenoma

17. Macrocystic Lesions
Mucinous cystic neoplasms
Intraductal Papillary Mucinous Neoplasm (IPMN)

18. Cysts with a solid component
Unilocular or multilocular
True cystic tumors or solid pancreatic neoplasms with cystic
component/degeneration
 Solid pseudopapillary tumor (SPEN)
 Mucinous cystic neoplasms
 IPMNs
 Islet cell tumor
 Adenocarcinoma
 Metastasis

19. Pancreatic Pseudocyst
Symptoms
Abdominal pain (80 – 90%)
 Lump in abdomen
 Nausea / vomiting ( due to gastric or duodenal compression)
 Early satiety
 Bloating, indigestion
 Jaundice ( due to compression of bile duct)
 Hemorrhage

20. Blood tests in suspected pseudocyst
Amylase/Lipase
Signs
 Tenderness
 Abdominal fullness
 Palpable mass

21. ImaginginPseudocyst…..
Ultrasonography
Most practical & Sensitivity (75 – 90%)
limited by patient habitus, operator experience and air in
stomach
CT scan
Gold standard for initial assessment and follow-up
Sensitivity 90- 100%

22. MRI
Better detail of content of cyst
MRCP
Establish the relationship of the pseudocyst to the pancreatic ducts
Endoscopic Ultrasonography (EUS +/- FNA)
Distinguishing pancreatic cystic lesions, helps in FNA

23. When a cysticlesions with…..
Sudden onset of pain consistent with pancreatitis pain
Imaging features of associatedpancreatitis
Unilocular cyst;and
Elevated amylase/lipase

24. Common Cystic neoplasm

25. MUCINOUS CYSTIC NEOPLASMS
Most common - 10% to 45% (MCA -67%, MCAC - 33%)
> 95% in women ( Mean ~ 50 yrs)
 Typically involve the body and tail of the pancreas
Never multifocal, occurring only in one location within
the pancreas.

26. Asymptomatic in 75% cases
 If symptoms, usually due to mass effect
 Adominal pain
 Palpable mass

27. Complex macrocystic mass with internal septations
 MRCP no communication between duct and the cyst
Contrast enhanced scans show enhancement of the cyst wall a
accentuate any septations and mural nodules
Presence of mural nodule and septal calcification s/o –
malignancy

28.  EUS can identify septations and cyst wall nodules In more
detail than MRI or CT
Allows cyst wall biopsy and cyst fluid aspiration for analysis
Cyst fluid analysis generally reveals
thick and mucoid material and low fluid amylase
elevated tumor markers (CEA)
mucinous epithelial cells by cytology

29. Mucinous Cystadenocarcinoma
Complex macrocystic lesion with internal septations
Peripheral and septal calcification indicative of malignancy
(arrowheads)

30. SEROUS CYSTADENOMAS
 Second MC Cystic tumor of the pancreas
formerly known as microcystic adenomas
 Occurring mostly in women (75%) with a mean 62 years
 Most (50% to 70%) occur in the body or tail of the pancreas
 An association with von Hippel-Lindau disease
 Mostly asymptomatic
 detected during evaluation for other unrelated conditions

31. Serous Cystadenoma
Lesion with numerous microcysts
“honey-comb” appearance
Lobulated outline Central stellate scar

32. Serous cystadenoma
 Pathognomonic image by CT scan:
 spongy mass with a central “sunburst” calcification -
10%
4 /5 CT and MRI features makes diagnosis
location in the pancreatic body and tail
 wall thickness < 2 mm
lobulated contour
lack of communication with the pancreatic duct
minimal wa ll enhancement

33. Intra-ductal PapillaryMucinousNeoplasm
Types
depend on involvement of duct
main pancreatic duct, isolated side branches, or a combination
of both
Benign (adenoma), borderline, or malignant
Malignant neoplasms account for 60% of IPMNs

34.  Equal frequency in men and women
 Median age at diagnosis - about 65 years
75% of patients are symptomatic
Abdominal pain and weight loss – MC complaints
Recurrent pancreatitis or Acute pancreatitis
Patients with malignant neoplasms are more likely to be
 older and more likely to present with jaundice or new-
onset diabetes

35. Diagnosis
Differentiation of IPMN from other cystic pancreatic masses may be
difficult at CT
Most reliable findings for the diagnosis
 Presence of a communication between the cystic lesion andthe main
pancreatic duct
 Presence of mural nodules projecting into the main pancreatic duct or
cystic lesions
Diffusely distended pancreatic duct with mucinous filling defects and grape-
like, cystic, space-occupying lesions
Sensitivity in diagnosing an IPMN
Highest for MRI with MRCP (88%),followed by ERCP (68%)and CT (42%)

36. Pathognomonic for IPMN in ERCP
A wide and gaping papilla with secretion of mucin and filling
defects in the dilated pancreatic duct –FISH MOUTH
AMPULLA

37. Features of Concern

40. Cysticlesionsof pancreas; will blood tests
help?
Amylase and/or Lipase??
CEA? Ca 19-9 ??
Not diagnostic of any of the cystic pancreatic tumors
Only provide corroborative evidence

41.  Serum amylaseor lipase levels
Increased - Pseudocyst, IPMN
 Serum CA19-9& CEA
Normal - benign cystic pancreatic tumors
Modestly elevated - MCNs and IPMNs, particularly
patients with malignancies
Markedlyelevated -retention cyst secondary to obstruction
of the main pancreatic duct by anadenocarcinoma.

42. Viscosity Amylase Cytology
Pseudocyst Low High Inflamm.
SCA Low Low 5% +
MCA High Low 40% +
MCAC High Low 67% +
CEA CA 15-3 CA 72-4
Pseudocyst Low Low Low
SCA Low Low Low
MCA High High Low
MCAC High High High
1 Lewandrowski KB, et al. Ann Surg 1993,217:41-7.
2 Brugge WR, et al. N Engl J Med 2004,351:1218-26.
Cyst Fluid Analysis

44. Comingbackto ourcase…
What could be our
diagnosis???

45. Pancreatic Pseudocyst

46. Thank You