Cystic neoplasms of the pancreas are relatively rare tumors that can be divided into four main types: serous cystic neoplasms (SCN), mucinous cystic neoplasms (MCN), intraductal papillary mucinous neoplasms (IPMN), and solid pseudopapillary neoplasms. SCNs are usually benign and surgical resection is only recommended for large or symptomatic cysts. MCNs and IPMNs have greater malignant potential and surgical resection is generally recommended due to the risk of cancer. IPMNs are further classified as main duct, branch duct, or mixed and location and histological subtype influence malignant risk and management. Surveillance with MRI is recommended post

1. Cystic Neoplasm of
Pancreas
Dr. Diwan Shrestha
MS Resident

2. Introduction
• Second most common exocrine pancreatic neoplasm
• Relatively rare neoplasm
• 1% of all panceatic neoplasm
• 10% of all cystic lesions of pancreas

3. WHO classification of
pancreatic cystic neoplasms
1. Serous cystic neoplasm (SCN)
 Serous microcystic adenoma
 Serous macrocystic adenoma
 Serous oligocystic adenoma
 Serous cystadenocarcionoma
2. Mucinous cystic neoplasm (MCN)
 Mucinous cystadenoma
 Mucinous cystic neoplasm with moderate dysplasia
 Mucinous cystadenocarcinoma

4. WHO classification of
pancreatic cystic neoplasms
3. Intraductal papillary mucinous neoplasm (IPMN)
 Intraductal papillary mucinous adenoma
 Intraductal papillary mucinous neoplasm with moderate dysplasia
 Intraductal papillary mucinous carcinoma
4. Solid pseudopapillary neoplasm
 Solid pseudopapillary neoplasm
 Solid pseudopapillary carcinoma

5. Types of Cystic Neoplasm
• 3 most common type :
 SCN
 MCN
 IPMN
• Represent approx 90% of all PCNs
• MCN & IPMN
 Have the highest potential for malignant transformation
• SCN
 Almost always benign

6. Serous cystic neoplasm
• Female to male ratio (3:1)
• Average age 62 years
• Common in the head of pancreas
• Commonly present with vague abdominal pain
 Less frequently with weight loss and obstructive jaundice
• On gross inspection
 Large, well circumscribed mass
• Microscopic examination
 Multiloculated, glycogen-rich small cysts

7. Serous cystic neoplasm
• Central calcification with
radiating septa giving the
sunburst appearance
 Radiographic sign on CT
 10% to 20% of patients
• Tumor larger than 4 cm
more likely to be
symptomatic
 display a more rapid median
growth rate

8. Mucinous cystic neoplasm
• Most common cystic neoplasms of the pancreas
• Common in perimenopausal women
• Men rarely affected
• Mean age at presentation fifth decade
• Typically found in the body and tail of the pancreas
• Incidental MCN becoming increasingly common

9. Mucinous cystic neoplasm
• 50% patients present with vague abdominal pain
 30% have palpable abdominal mass
• History of pancreatitis may be found in up to 20% of
patients
• Tumors span the histologic spectrum from benign to
invasive carcinomas
 < 20% MCNs associated with invasive carcinoma
• MCNs contain mucin-producing epithelium
 Identified histologically by the presence of mucin-rich cells and ovarian-like
stroma

10. Mucinous cystic neoplasm
• CT scan
 Presence of a solitary cyst
 May have fine septations
 Surrounded by a rim of calcification
• Cross-sectional imaging
may not be able to
distinguish between benign
and malignant MCNs
 Presence of eggshell calcification
 Larger tumor size
 Mural nodule
 Suggestive of malignancy

11. Mucinous cystic neoplasm
• FNA with cyst fluid analysis of MCNs demonstrate
 Mucin-rich aspirate
 High CEA levels (>192 ng/mL)
• MCNs typically have low levels of cyst fluid amylase
• Stroma cells stain
 Estrogen (25-63%)
 Progesterone ( 50-80%)
 Alpha-inhibin (50-70%)
• Invasive MCNs exhibit
 Slower growth
 Less frequent nodal involvement
 Less aggressive clinical behavior
 Compared with ductal adenocarcinoma

12. Intraductal papillary mucinous
neoplasm
• First recognised in 1982 by Ohashi
• Defined as intraductal, grossly visible epithelial
neoplasm of mucin producing cells
• Approx 3-5% of all pancreatic tumors
• Peak incidence at 60-70 years
• More prevalent in males than female

13. Intraductal papillary mucinous
neoplasm
• Can be 3 types :
1. Main duct IPMN
 Approx 25% of IPMNs
 Segmental or diffuse dilation of MPD (>5mm) in the absence of other
causes of ductal obstruction
 MPD is mucin filled & tortous
 Common near the head of pancreas
 Adjacent pancreas can be fibrotic & firm due to chronic pancreatitis
 MD-IPMN have a 30% to 50% risk of harboring invasive pancreatic
cancer at the time of presentation

14. Intraductal papillary mucinous
neoplasm
2. Branch duct IPMN
 Approx 57% of IPMNs
 Involves dilation of the pancreatic duct side branches that
communicate with but do not involve the main pancreatic duct
 May be focal, involving a single side branch, or multifocal, with
multiple cystic lesions throughout the length of the pancreas
 Occur in slightly younger population
 Common in uncinate process
 Less associated with malignancy
 Grossly appear as grape like structure that are multicystic containing
mucin filled ducts
 Adjacent pancreas usually normal due to non involvement of main
pancreatic duct

15. Intraductal papillary
mucinous neoplasm
3. Mixed type IPMN
 Approx 18% of IPMNs
 A side branch IPMN that has extended to involve the main pancreatic duct
to a varying degree
 Meet criteria for both main & branch duct IPMN

16. Intraductal papillary mucinous
neoplasm
• Majority of IPMNs discovered incidentally
 Mostly asymptomatic
• When symptoms do occur
 Tend to be non specific
 Unexplained weight loss, abdominal pain, anorexia
 Jaundice due to mucin obstructing ampulla
 Obstruction of pancreatic duct can cause pancreatitis

17. Intraductal papillary mucinous
neoplasm

18. Intraductal papillary mucinous
neoplasm
• Triad of Ohashi
 Bulging ampulla of Vater
 Mucin secretion from patulous papilla
 Dilated main pancreatic duct

19. Intraductal papillary mucinous
neoplasm
• IPMNs based on epithelial lining of papillary component
categorised into
 Gastric
 Intestinal
 Pancreaticobiliary
 Oncocytic
• Branch duct IPMN mainly of gastric variant
• Main duct IPMNs mainly intestinal type

20. Intraductal papillary
mucinous neoplasm
• All cysts with worrisome
features on CT or MRI
and any cyst larger than
3 cm with or without
worrisome features
should undergo EUS
• All cysts with high-risk
features should be
resected

22. Management
Serous cystic neoplasm
• Nearly all SCNs are benign
• In older or frial patients
 Conservative approach
• Indications for operative management
 Presence of symptoms
 Cyst > 4 cm
 Uncertainty of diagnosis despite appropriate radiological assesment

23. Serous cystic neoplasm
• Type of surgical resection
 Based on position of cyst within the pancreas
• Can be
 Anatomic pancreatectomy ( pancreaticoduodenectomy or distal
pancreatectomy)
 Tissue preserving procedure ( segmental central pancreatectomy)
• No role for lymphadenectomy or extended resections
 Due to inherent benign nature

24. Mucinous cystic neoplasm
• Surgical resection irrespective of location in the
pancreas or size
• MCN in the head of pancreas
 Pancreaticoduodenectomy
• MCN in the body & tail of pancreas
 Distal pancreatectomy
• Concurrent splenectomy controversial
• Lymph node excision limited to immediate proximity of
pancreatic lesion

25. Intraductal papillary mucinous
neoplasm
• IPMN localised to body & tail
 Distal pancreatectomy with splenectomy
• IPMN localised to head or uncinate process
 pancreaticoduodenectomy

28. Intraductal papillary mucinous
neoplasm
• Endoscopic cyst ablation using ethanol or in combination
with Paclitaxel can be done
• Ablation can be done for
 Small cysts
 Patients with serous comorbidities
• Endoscopic ablation with ethanol contraindicated in
main duct IPMN
 Due to interaction of ethanol with the activation of zymogens resulting in acute
pancreatitis

29. Adjuvant therapy
• Patients with evidence of invasive disease on final
pathology even in the absence of positive margins
• Gemcitabine based chemotherapy with radiotherapy

30. Surveillance
• Modality of choice MRI
• CEA & CA 19-9 has
limited role for detection of
IPMN recurrence

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