A 27-year-old male presented with early satiety, recurrent vomiting, weight loss, and abdominal pain. Imaging revealed a large cystic lesion in the pancreas. Differential diagnoses for cystic pancreatic lesions include pseudocyst, serous cystadenoma, mucinous cystic neoplasm, and intraductial papillary mucinous neoplasm. Based on the presentation of abdominal pain following episodes of alcohol use and imaging findings of a well-defined cystic lesion surrounded by an enhancing wall, this case is most consistent with a pancreatic pseudocyst.

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