This document discusses cystic neoplasms of the pancreas. It begins by describing the etiology of pancreatic cystic masses, which can be congenital, inflammatory, or neoplastic. Common etiologies include pseudocysts resulting from pancreatitis and serous cystadenomas, which are benign tumors. Mucinous cystic neoplasms are also discussed and considered premalignant. Imaging and cyst fluid analysis are important for distinguishing between these different cyst types. Fine needle aspiration guided by endoscopic ultrasound can provide diagnostic samples. Management depends on the specific diagnosis and may include observation, drainage, or surgery.
Cystic Neoplasms of the Pancreas
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Pancreatic cystic neoplasm - Dr Dheeraj Yadavdheeraj_maddoc
This document discusses pancreatic cystic neoplasms, which are relatively rare pancreatic tumors. It describes the main types - serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). SCNs are usually benign and contain clear fluid, while MCNs and IPMNs have higher malignant potential and are often lined with mucin-secreting cells. Imaging plays an important role in diagnosis, with CT and MRI identifying characteristics such as central scarring in SCNs. Complete surgical resection is typically recommended for suspected malignant neoplasms.
Pancreatic cystic neoplasm: Definition, Classification, Diagnosis and treatment.Marco Castillo
A brief description of the different pancreatic cystic neoplasms and the pseudocyst, including, eidemiology, classification, risk of malignancy, histology, imaging techniques for diagnosis and treatment.
1. Cystic neoplasms of the pancreas include serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs), which represent approximately 90% of cases.
2. SCNs have little malignant potential and surgery is only recommended for symptomatic cases or diagnostic uncertainty. MCNs and IPMNs have higher malignant potential related to size and presence of mural nodules.
3. Differentiating between SCNs, MCNs and IPMNs requires imaging like MRI/CT along with cyst fluid analysis and pathology given differences in histology, genetic factors and malignant
The document discusses various types of cystic tumors and lesions that can occur in the pancreas. It describes congenital lesions such as those seen in autosomal dominant polycystic kidney disease. Inflammatory lesions like pseudocysts are discussed as are exocrine pancreatic lesions including microcystic adenomas, mucinous cystic tumors, and intraductal papillary mucinous tumors. For each type of lesion or tumor, the document provides details on characteristics, imaging appearance, pathology, and prognosis.
This document discusses pancreatic cysts, describing the different types that exist including true cysts, pseudocysts, cystic neoplasms, and discusses features that help differentiate them. Key features of serous cystic neoplasms, intraductal papillary mucinous neoplasms, and mucinous cystic neoplasms are provided. Endoscopic ultrasound is an important tool for evaluating pancreatic cysts, allowing for high resolution imaging and fine needle aspiration, though it has limitations including sampling error. Findings on EUS that suggest surgery include detecting mural nodules or involvement of the main pancreatic duct.
The document summarizes different types of cystic lesions of the pancreas that can be identified on MRI imaging. It describes pseudocysts as the most common type, occurring due to pancreatitis. Serous cystadenomas appear as clusters of small cysts with enhancing septa and a central scar. Mucinous cysts can be non-neoplastic or neoplastic cystadenomas and cystadenocarcinomas, appearing as thick-walled cysts that may enhance. Intraductal papillary mucinous neoplasms involve the pancreatic ducts.
This document summarizes a radiology department meeting discussing the imaging and management of pancreatic cystic lesions. It provides an overview of different types of cystic pancreatic lesions including pseudocysts, serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms (IPMN). For each type, the document describes key imaging features, pathology, and clinical management considerations. Endoscopic ultrasound is also discussed as a useful adjunct for evaluating cystic lesions through aspiration and sampling. The document concludes with recommendations on follow-up imaging intervals and pearls to help differentiate different cystic pancreatic lesions based on factors like age, gender, location, presence of calcification, and duct
Cystic Neoplasms of the Pancreas
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Pancreatic cystic neoplasm - Dr Dheeraj Yadavdheeraj_maddoc
This document discusses pancreatic cystic neoplasms, which are relatively rare pancreatic tumors. It describes the main types - serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). SCNs are usually benign and contain clear fluid, while MCNs and IPMNs have higher malignant potential and are often lined with mucin-secreting cells. Imaging plays an important role in diagnosis, with CT and MRI identifying characteristics such as central scarring in SCNs. Complete surgical resection is typically recommended for suspected malignant neoplasms.
Pancreatic cystic neoplasm: Definition, Classification, Diagnosis and treatment.Marco Castillo
A brief description of the different pancreatic cystic neoplasms and the pseudocyst, including, eidemiology, classification, risk of malignancy, histology, imaging techniques for diagnosis and treatment.
1. Cystic neoplasms of the pancreas include serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs), which represent approximately 90% of cases.
2. SCNs have little malignant potential and surgery is only recommended for symptomatic cases or diagnostic uncertainty. MCNs and IPMNs have higher malignant potential related to size and presence of mural nodules.
3. Differentiating between SCNs, MCNs and IPMNs requires imaging like MRI/CT along with cyst fluid analysis and pathology given differences in histology, genetic factors and malignant
The document discusses various types of cystic tumors and lesions that can occur in the pancreas. It describes congenital lesions such as those seen in autosomal dominant polycystic kidney disease. Inflammatory lesions like pseudocysts are discussed as are exocrine pancreatic lesions including microcystic adenomas, mucinous cystic tumors, and intraductal papillary mucinous tumors. For each type of lesion or tumor, the document provides details on characteristics, imaging appearance, pathology, and prognosis.
This document discusses pancreatic cysts, describing the different types that exist including true cysts, pseudocysts, cystic neoplasms, and discusses features that help differentiate them. Key features of serous cystic neoplasms, intraductal papillary mucinous neoplasms, and mucinous cystic neoplasms are provided. Endoscopic ultrasound is an important tool for evaluating pancreatic cysts, allowing for high resolution imaging and fine needle aspiration, though it has limitations including sampling error. Findings on EUS that suggest surgery include detecting mural nodules or involvement of the main pancreatic duct.
The document summarizes different types of cystic lesions of the pancreas that can be identified on MRI imaging. It describes pseudocysts as the most common type, occurring due to pancreatitis. Serous cystadenomas appear as clusters of small cysts with enhancing septa and a central scar. Mucinous cysts can be non-neoplastic or neoplastic cystadenomas and cystadenocarcinomas, appearing as thick-walled cysts that may enhance. Intraductal papillary mucinous neoplasms involve the pancreatic ducts.
This document summarizes a radiology department meeting discussing the imaging and management of pancreatic cystic lesions. It provides an overview of different types of cystic pancreatic lesions including pseudocysts, serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms (IPMN). For each type, the document describes key imaging features, pathology, and clinical management considerations. Endoscopic ultrasound is also discussed as a useful adjunct for evaluating cystic lesions through aspiration and sampling. The document concludes with recommendations on follow-up imaging intervals and pearls to help differentiate different cystic pancreatic lesions based on factors like age, gender, location, presence of calcification, and duct
This document discusses cystic pancreatic tumours, focusing on intraductal papillary mucinous neoplasms (IPMN). IPMNs are rare cystic tumours arising from the pancreatic duct epithelium that cause duct dilation and mucin secretion. On imaging, main duct IPMN displays diffuse or segmental pancreatic duct dilation filled with mucin, while branch duct IPMN shows single or multiple dilated side branches. Mural nodules or solid components indicate higher malignancy risk. Surgical resection is recommended for main duct IPMN due to high malignancy risk, while branch duct IPMN may be surveilled if small with no malignant features. Differential diagnosis includes serous cystadenoma, mucinous cystic ne
This document discusses the evaluation and management of cystic tumors of the pancreas. It notes that the most common types are serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Initial imaging includes MRI with MRCP and EUS with FNA to characterize the cyst. Cyst fluid analysis is important to distinguish malignant potential. Small asymptomatic cysts may only need follow up imaging. Surveillance is recommended for certain non-surgical cases, monitoring for changes or malignant progression over multiple years.
1. Incidental cystic lesions of the pancreas are being discovered more frequently, occurring in approximately 1% of abdominal imaging studies.
2. Differentiating benign from premalignant or malignant cystic lesions is challenging but important, as it determines appropriate management and surveillance approaches.
3. Current guidelines recommend surgical resection for mucinous pancreatic cystic lesions showing worrisome features such as cyst size over 3 cm, mural nodules, or involvement of the main pancreatic duct, due to their elevated risk of harboring cancer.
This document discusses pancreatic cysts and cystic neoplasms. It provides information on different types of cysts including pseudocysts, serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Key points include that pancreatic cysts are increasingly detected due to improved imaging but can be challenging to diagnose definitively. Endoscopic ultrasound with potential fluid sampling is often needed to characterize cysts, though accuracy depends on experience. Malignant potential varies between cyst types and certain features like size, wall thickness, and presence of nodules impact cancer risk assessment.
1. Serous cystadenomas are benign pancreatic neoplasms that appear as large, multiloculated cystic masses filled with serous fluid.
2. Mucinous cystic neoplasms predominantly affect women and present as large, well-encapsulated tumors with mucoid contents that may become calcified.
3. Pancreatic ductal adenocarcinoma is an aggressive cancer that often presents at an advanced stage with vague symptoms. Microscopically it is characterized by a desmoplastic response and highly invasive growth pattern.
Diagnosis And Management Of Pancreatic Cystic LesionMyounghwan Kim
The document discusses the diagnosis and management of pancreatic cystic lesions. It is often difficult to differentiate between pseudocysts and cystic neoplasms based on clinical, radiologic, and pathologic features alone. Pseudocysts are the most common type but accurate diagnosis is important to determine proper treatment. Incidental pancreatic cysts found in asymptomatic patients also pose diagnostic challenges. The document provides guidelines on evaluating patients' history, cyst features on imaging, and tumor markers to distinguish between lesion types and recommends appropriate management strategies.
The slide presentation summarizes cytology findings of pancreatic cytology from a 28-year-old female. Smears showed loosely cohesive tissue fragments and scattered cells in a clean background with absent or scanty cytoplasm. Nuclei were round to oval with stippled chromatin. Features were consistent with pancreatic neuroendocrine neoplasm rather than solid pseudopapillary tumor. The presentation reviewed pancreatic development, indications for FNA, reporting systems, and findings associated with primary pancreatic neoplasms including neuroendocrine tumors.
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.
This document discusses the imaging findings and differential diagnosis of pancreatic cystic lesions. It begins by outlining the purpose and learning objectives, which are to identify and describe the radiologic findings of pancreatic pseudocysts and cystic neoplasms, and discuss how to differentiate between them. The majority of the document then focuses on describing the typical imaging appearance of pancreatic pseudocysts and various cystic neoplasms like serous cystadenoma, and highlighting clues that can help distinguish between them.
This document discusses pancreatic cystic neoplasms, which are relatively rare pancreatic tumors that are increasingly detected. It describes the main types of cystic neoplasms including serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary neoplasms. For each type, it covers epidemiology, pathology, clinical presentation, diagnostic imaging features, malignant potential, treatment options, and prognosis. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have greater malignant potential compared to serous cystadenomas which are almost always benign. Complete surgical resection is the primary treatment for resectable lesions while surveillance imaging
Pancreatic Cysts: A Contemporary ApproachJarrod Lee
Pancreatic cysts are increasingly found during abdominal imaging. Although the majority will not cause any problems, a minority may enlarge or become malignant. We present a contemporary approach to managing pancreatic cysts, utilizing the latest evidence, technologies and endoscopic procedures. We identify which cysts need surveillance or even surgery, and which can be safely ignored.
Pancreatic neoplasms can be classified based on their function as exocrine tumors, endocrine tumors, or mesenchymal tumors. The most common pancreatic neoplasm is pancreatic ductal adenocarcinoma, which arises from the exocrine pancreatic ductal cells. Endocrine tumors arise from the islet cells and include functional tumors like insulinomas and non-functional tumors. Rare pancreatic mesenchymal neoplasms originate from the pancreatic structural elements and include both benign and malignant subtypes.
This document discusses benign and malignant lesions of the intestines. It begins by providing background on the intestines and burden of colorectal cancer worldwide. It then describes the histology and patterns of abnormality seen in small intestinal biopsies for various conditions like celiac disease, tropical sprue, stasis syndromes, and Whipple's disease. It also discusses the histologic patterns seen in colonic inflammation and different types of active colitis.
This document discusses imaging of the pancreas. Ultrasound and CT scan are the primary modalities used. Ultrasound is useful as a screening tool due to its availability, low cost and lack of radiation. CT scan is the gold standard modality as it can accurately detect pancreatic abnormalities and complications. MRCP and MRI provide additional information and are used as problem-solving tools. The document reviews imaging features of various pancreatic pathologies such as acute pancreatitis, chronic pancreatitis, tumors and trauma.
The document discusses various cystic lesions of the pancreas that can be identified on medical imaging. It describes the typical imaging appearance of pseudocysts, which appear as well-defined fluid collections after pancreatitis or trauma. It also covers the imaging characteristics of different cystic pancreatic neoplasms, such as serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. The document emphasizes that cystic neoplasms often require surgical resection due to their malignant potential, whereas pseudocysts can often be managed non-operatively.
A 45-year-old female presented with recurrent vomiting, loss of appetite, abdominal pain, and significant weight loss over 6 months. Imaging revealed a 7x5cm cystic lesion in the pancreatic head and neck. The differential diagnosis for cystic pancreatic lesions includes pseudocyst, serous cystadenoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, and rarer entities. Specific imaging features, cyst fluid analysis, and clinical characteristics can help differentiate these potential diagnoses to guide management of the patient's cystic pancreatic lesion.
This document discusses pancreatic adenocarcinoma and assessing resectability with CT imaging. It provides background on pancreatic cancer and details CT findings that indicate:
1) The tumor is locally advanced and surrounds blood vessels, making it unresectable.
2) Distant metastases are present, such as small liver lesions typical of metastases or enlarged lymph nodes, also making the tumor unresectable.
3) Complete surgical resection, which offers the only chance of cure, requires that the tumor can be safely removed without involvement of nearby structures.
Acute pancreatitis and Pancreatic CarcinomaBauwa1971
This document discusses pancreatitis and pancreatic carcinoma. It begins by outlining the objectives of understanding the etiology and pathogenesis of chronic pancreatitis, clinical diagnosis of pancreatitis, and principles of managing pancreatitis and pancreatic carcinoma. It then covers the relevant anatomy of the pancreas and its relationships to neighboring structures. Chronic pancreatitis is defined as an irreversible inflammatory disease causing pancreatic tissue destruction. Etiologies include alcohol, hereditary factors, obstruction, and metabolic causes. Clinical features involve recurrent abdominal pain, weight loss, steatorrhea, and symptoms of endocrine insufficiency. Pancreatic carcinoma has a poor prognosis, with ductal adenocarcinoma being the most common type. Risk factors include chronic pancreatitis
Pseudocyst of the pancreas and benign cystic neoplasms are two types of pancreatic cysts that can develop. Pseudocysts are collections of fluid that develop after pancreatitis and usually resolve on their own, but sometimes persist and cause complications. Benign cystic neoplasms include mucinous cystic neoplasms that are more common in women and involve mucin-producing epithelium, and intraductal papillary mucinous neoplasms which involve cystic growths and epithelial changes along the pancreatic ducts. Both conditions are generally diagnosed using imaging tests and investigated further if complications arise or if malignancy cannot be ruled out, with surgical resection as the treatment in some cases.
This document provides information on pancreatic neoplasms. It begins with the anatomy of the pancreas and its blood supply. It then discusses the different types of pancreatic neoplasms, including cystic neoplasms and ductal adenocarcinoma. Risk factors for ductal adenocarcinoma are outlined. The pathogenesis and molecular progression of pancreatic cancer from pancreatic intraepithelial neoplasia to invasive cancer is described. Clinical presentation, diagnostic imaging modalities, staging, treatment options including surgery and adjuvant therapy, palliative care, and recent advances are summarized. Finally, cystic neoplasms of the pancreas including mucinous cystic neoplasms are briefly covered.
This document discusses cystic pancreatic tumours, focusing on intraductal papillary mucinous neoplasms (IPMN). IPMNs are rare cystic tumours arising from the pancreatic duct epithelium that cause duct dilation and mucin secretion. On imaging, main duct IPMN displays diffuse or segmental pancreatic duct dilation filled with mucin, while branch duct IPMN shows single or multiple dilated side branches. Mural nodules or solid components indicate higher malignancy risk. Surgical resection is recommended for main duct IPMN due to high malignancy risk, while branch duct IPMN may be surveilled if small with no malignant features. Differential diagnosis includes serous cystadenoma, mucinous cystic ne
This document discusses the evaluation and management of cystic tumors of the pancreas. It notes that the most common types are serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Initial imaging includes MRI with MRCP and EUS with FNA to characterize the cyst. Cyst fluid analysis is important to distinguish malignant potential. Small asymptomatic cysts may only need follow up imaging. Surveillance is recommended for certain non-surgical cases, monitoring for changes or malignant progression over multiple years.
1. Incidental cystic lesions of the pancreas are being discovered more frequently, occurring in approximately 1% of abdominal imaging studies.
2. Differentiating benign from premalignant or malignant cystic lesions is challenging but important, as it determines appropriate management and surveillance approaches.
3. Current guidelines recommend surgical resection for mucinous pancreatic cystic lesions showing worrisome features such as cyst size over 3 cm, mural nodules, or involvement of the main pancreatic duct, due to their elevated risk of harboring cancer.
This document discusses pancreatic cysts and cystic neoplasms. It provides information on different types of cysts including pseudocysts, serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Key points include that pancreatic cysts are increasingly detected due to improved imaging but can be challenging to diagnose definitively. Endoscopic ultrasound with potential fluid sampling is often needed to characterize cysts, though accuracy depends on experience. Malignant potential varies between cyst types and certain features like size, wall thickness, and presence of nodules impact cancer risk assessment.
1. Serous cystadenomas are benign pancreatic neoplasms that appear as large, multiloculated cystic masses filled with serous fluid.
2. Mucinous cystic neoplasms predominantly affect women and present as large, well-encapsulated tumors with mucoid contents that may become calcified.
3. Pancreatic ductal adenocarcinoma is an aggressive cancer that often presents at an advanced stage with vague symptoms. Microscopically it is characterized by a desmoplastic response and highly invasive growth pattern.
Diagnosis And Management Of Pancreatic Cystic LesionMyounghwan Kim
The document discusses the diagnosis and management of pancreatic cystic lesions. It is often difficult to differentiate between pseudocysts and cystic neoplasms based on clinical, radiologic, and pathologic features alone. Pseudocysts are the most common type but accurate diagnosis is important to determine proper treatment. Incidental pancreatic cysts found in asymptomatic patients also pose diagnostic challenges. The document provides guidelines on evaluating patients' history, cyst features on imaging, and tumor markers to distinguish between lesion types and recommends appropriate management strategies.
The slide presentation summarizes cytology findings of pancreatic cytology from a 28-year-old female. Smears showed loosely cohesive tissue fragments and scattered cells in a clean background with absent or scanty cytoplasm. Nuclei were round to oval with stippled chromatin. Features were consistent with pancreatic neuroendocrine neoplasm rather than solid pseudopapillary tumor. The presentation reviewed pancreatic development, indications for FNA, reporting systems, and findings associated with primary pancreatic neoplasms including neuroendocrine tumors.
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.
This document discusses the imaging findings and differential diagnosis of pancreatic cystic lesions. It begins by outlining the purpose and learning objectives, which are to identify and describe the radiologic findings of pancreatic pseudocysts and cystic neoplasms, and discuss how to differentiate between them. The majority of the document then focuses on describing the typical imaging appearance of pancreatic pseudocysts and various cystic neoplasms like serous cystadenoma, and highlighting clues that can help distinguish between them.
This document discusses pancreatic cystic neoplasms, which are relatively rare pancreatic tumors that are increasingly detected. It describes the main types of cystic neoplasms including serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary neoplasms. For each type, it covers epidemiology, pathology, clinical presentation, diagnostic imaging features, malignant potential, treatment options, and prognosis. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have greater malignant potential compared to serous cystadenomas which are almost always benign. Complete surgical resection is the primary treatment for resectable lesions while surveillance imaging
Pancreatic Cysts: A Contemporary ApproachJarrod Lee
Pancreatic cysts are increasingly found during abdominal imaging. Although the majority will not cause any problems, a minority may enlarge or become malignant. We present a contemporary approach to managing pancreatic cysts, utilizing the latest evidence, technologies and endoscopic procedures. We identify which cysts need surveillance or even surgery, and which can be safely ignored.
Pancreatic neoplasms can be classified based on their function as exocrine tumors, endocrine tumors, or mesenchymal tumors. The most common pancreatic neoplasm is pancreatic ductal adenocarcinoma, which arises from the exocrine pancreatic ductal cells. Endocrine tumors arise from the islet cells and include functional tumors like insulinomas and non-functional tumors. Rare pancreatic mesenchymal neoplasms originate from the pancreatic structural elements and include both benign and malignant subtypes.
This document discusses benign and malignant lesions of the intestines. It begins by providing background on the intestines and burden of colorectal cancer worldwide. It then describes the histology and patterns of abnormality seen in small intestinal biopsies for various conditions like celiac disease, tropical sprue, stasis syndromes, and Whipple's disease. It also discusses the histologic patterns seen in colonic inflammation and different types of active colitis.
This document discusses imaging of the pancreas. Ultrasound and CT scan are the primary modalities used. Ultrasound is useful as a screening tool due to its availability, low cost and lack of radiation. CT scan is the gold standard modality as it can accurately detect pancreatic abnormalities and complications. MRCP and MRI provide additional information and are used as problem-solving tools. The document reviews imaging features of various pancreatic pathologies such as acute pancreatitis, chronic pancreatitis, tumors and trauma.
The document discusses various cystic lesions of the pancreas that can be identified on medical imaging. It describes the typical imaging appearance of pseudocysts, which appear as well-defined fluid collections after pancreatitis or trauma. It also covers the imaging characteristics of different cystic pancreatic neoplasms, such as serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. The document emphasizes that cystic neoplasms often require surgical resection due to their malignant potential, whereas pseudocysts can often be managed non-operatively.
A 45-year-old female presented with recurrent vomiting, loss of appetite, abdominal pain, and significant weight loss over 6 months. Imaging revealed a 7x5cm cystic lesion in the pancreatic head and neck. The differential diagnosis for cystic pancreatic lesions includes pseudocyst, serous cystadenoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, and rarer entities. Specific imaging features, cyst fluid analysis, and clinical characteristics can help differentiate these potential diagnoses to guide management of the patient's cystic pancreatic lesion.
This document discusses pancreatic adenocarcinoma and assessing resectability with CT imaging. It provides background on pancreatic cancer and details CT findings that indicate:
1) The tumor is locally advanced and surrounds blood vessels, making it unresectable.
2) Distant metastases are present, such as small liver lesions typical of metastases or enlarged lymph nodes, also making the tumor unresectable.
3) Complete surgical resection, which offers the only chance of cure, requires that the tumor can be safely removed without involvement of nearby structures.
Acute pancreatitis and Pancreatic CarcinomaBauwa1971
This document discusses pancreatitis and pancreatic carcinoma. It begins by outlining the objectives of understanding the etiology and pathogenesis of chronic pancreatitis, clinical diagnosis of pancreatitis, and principles of managing pancreatitis and pancreatic carcinoma. It then covers the relevant anatomy of the pancreas and its relationships to neighboring structures. Chronic pancreatitis is defined as an irreversible inflammatory disease causing pancreatic tissue destruction. Etiologies include alcohol, hereditary factors, obstruction, and metabolic causes. Clinical features involve recurrent abdominal pain, weight loss, steatorrhea, and symptoms of endocrine insufficiency. Pancreatic carcinoma has a poor prognosis, with ductal adenocarcinoma being the most common type. Risk factors include chronic pancreatitis
Pseudocyst of the pancreas and benign cystic neoplasms are two types of pancreatic cysts that can develop. Pseudocysts are collections of fluid that develop after pancreatitis and usually resolve on their own, but sometimes persist and cause complications. Benign cystic neoplasms include mucinous cystic neoplasms that are more common in women and involve mucin-producing epithelium, and intraductal papillary mucinous neoplasms which involve cystic growths and epithelial changes along the pancreatic ducts. Both conditions are generally diagnosed using imaging tests and investigated further if complications arise or if malignancy cannot be ruled out, with surgical resection as the treatment in some cases.
This document provides information on pancreatic neoplasms. It begins with the anatomy of the pancreas and its blood supply. It then discusses the different types of pancreatic neoplasms, including cystic neoplasms and ductal adenocarcinoma. Risk factors for ductal adenocarcinoma are outlined. The pathogenesis and molecular progression of pancreatic cancer from pancreatic intraepithelial neoplasia to invasive cancer is described. Clinical presentation, diagnostic imaging modalities, staging, treatment options including surgery and adjuvant therapy, palliative care, and recent advances are summarized. Finally, cystic neoplasms of the pancreas including mucinous cystic neoplasms are briefly covered.
This document provides guidelines for the diagnosis and management of cystic pancreatic lesions. It discusses various types of cystic masses that can occur in the pancreas such as pseudocysts, serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms (IPMN), and solid pseudo-papillary tumors. For each type, it provides information on characteristics, malignant potential, imaging appearance, and treatment approach. Initial evaluation of pancreatic cysts should aim to exclude pseudocysts based on history of pancreatitis. Morphological evaluation and cyst fluid analysis via EUS and FNA are important diagnostic tools to characterize cyst type and guide management.
Este documento presenta información sobre tres procesos macro de administración de la cadena de suministro: administración de la relación con el proveedor (ARP), administración de la cadena de suministro interna (ACSI) y administración de las relaciones con los clientes (ARC). Describe los procesos clave de cada uno y cómo deben integrarse para mejorar el desempeño general de la cadena de suministro. La integración entre los procesos de ARP, ACSI y ARC es crucial para satisfacer la demanda de los clientes de manera eficiente.
Basepin offers a web-based project coordination system that facilitates design coordination, issue tracking, document management, closeout processes, and team collaboration. It provides an affordable solution for managing complex MEPS coordination and expediting project completion. The system establishes common rules and access for project teams, integrating documentation with 3D models and enabling remote coordination and meetings. Customers report that Basepin saves costs by reducing RFIs, travel, and punchlist hours.
We are currently working on structural designs for ongoing projects in association with M/s. Jaisim Fountainhead Architects in Bangalore. Our structural designs ensure safety and stability for constructions. We provide efficient and effective structural design solutions.
Este documento describe los elementos clave de un liderazgo ético y transformador. Argumenta que el liderazgo es una actitud accesible para todos, no solo para aquellos en posiciones de autoridad. Luego identifica tres virtudes esenciales de este tipo de liderazgo: congruencia, aceptación y comunicación. La congruencia significa mantener una conducta íntegra en privado y público. La aceptación genera un clima de seguridad al aceptar a las personas tal como son. Y la comunicación honesta y abierta permite ver las cosas desde la
This document discusses crayons and how they are made. It provides information about the main ingredients of crayons, the most popular crayon color, and how the first crayons were marketed. It also describes the process for making Crayola crayons and includes a math story problem about using tape to seal crayon packages. The document promotes donating crayons and mentions an orphanage in Ghana that could benefit from crayon donations.
This document discusses blended learning and the tools that can be used to support it. Blended learning combines face-to-face and online elements to support teaching and learning. When determining which technology tools to use, instructors should base their choices on the existing learning activities and their experience level. The document then describes several tools that can be used for blended learning, including the ANGEL modules, The Commons, Google Presentations, MindMeister, and Dropbox. It provides links to each tool to help instructors integrate technology into their blended courses.
The document discusses the results of a study on the effects of exercise on memory and thinking abilities in older adults. The study found that regular exercise led to improvements in memory, planning abilities, and attention span in adults aged 60-79 who exercised aerobically for 150 minutes per week. Exercising helped increase blood flow and oxygen to the brain which supported brain health as adults aged.
This document discusses the imaging features of various cystic lesions of the pancreas. It begins by describing pseudocysts, which typically occur after acute pancreatitis and appear as well-defined fluid collections on imaging. It then covers the common cystic pancreatic neoplasms such as serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms (IPMN). Key distinguishing imaging features between these lesions include their location in the pancreas, presence of septations, calcifications, and communication with the pancreatic duct. The document provides imaging examples and emphasizes the importance of differentiating malignant from benign cystic lesions.
This document summarizes various pathologies that can present as cystic or solid masses in the peritoneum based on CT imaging findings. It describes mucinous carcinomatosis, pseudomyxoma peritonei, lymphangioma, enteric duplication cyst, tuberculosis, echinococcal cyst, peritoneal metastases, lymphoma, carcinoid tumors, gastrointestinal stromal tumors, inflammatory pseudotumor, desmoid tumors, sclerosing mesenteritis, malignant mesothelioma, primary peritoneal serous carcinoma and desmoplastic small round cell tumor. Key distinguishing imaging features for each condition are provided.
The document discusses several benign breast lesions and conditions:
- Mammary duct ectasia, which involves ectasia and thickening of large ducts with accumulation of debris, calcification, and chronic inflammation.
- Fibrocystic changes and sclerosing lesions, which present as multiple nodules involving glandular proliferation and compression.
- Columnar cell lesions, including simple columnar cell change, columnar cell hyperplasia, and lesions with atypia, the earliest neoplastic changes.
- Inflammatory conditions such as fat necrosis, mastitis, and granulomatous lobulitis. These can mimic carcinoma clinically and mammographically.
Imaging of non endocrine tumour of pancreasDev Lakhera
Pancreatic malignancies are typically adenocarcinomas originating from duct cells. CT and MRI are important for staging and detecting signs of unresectability. On CT, pancreatic adenocarcinomas usually appear as ill-defined, hypoenhancing masses with desmoplastic reactions and tendencies to obstruct ducts. Features indicating unresectability include vascular encasement or ingrowth. Cystic pancreatic lesions include serous cystadenomas and mucinous cystic neoplasms, which are often indistinguishable on imaging alone. Intraductal papillary mucinous neoplasms involve main or branch duct dilation.
The document discusses ultrasound imaging of the pancreas. It provides information on normal pancreatic anatomy and measurements to evaluate. Common pathological conditions that can be identified with ultrasound include pancreatic lipomatosis, cysts, pancreatitis, pseudocysts, chronic pancreatitis, tumors, and endocrine tumors. Images demonstrate ultrasound findings of these various normal and abnormal pancreatic conditions.
This document provides an overview of various types of pancreatic neoplasms, including:
1. Ductal adenocarcinoma, which accounts for 90% of pancreatic cancers.
2. Cystic pancreatic neoplasms such as serous cystadenomas and mucinous cystic neoplasms.
3. Intraductal neoplasms including intraductal papillary mucinous neoplasms and intraductal tubular neoplasms.
4. Acinar cell tumors, the most common being acinar cell carcinoma.
5. Other rare tumors such as pancreatoblastoma, solid pseudopapillary tumor, and pancreatic neuroendocrine tumors.
Detailed information
A 20-year-old female presented with a 3-month history of abdominal lump and intermittent abdominal pain. Imaging showed a well-defined predominantly cystic lesion with an enhancing solid peripheral component arising from the head of the pancreas, without communication to the pancreatic duct. There were no findings of calcification, loculation, infiltration or metastasis. The diagnosis was determined to be a solid pseudopapillary epithelial neoplasm of the pancreas (SPEN) based on the characteristics of the lesion. The patient's case was then discussed and questions were presented to assess differentiating features of cystic pancreatic lesions.
This document provides an overview of pancreatic masses, including a classification system and descriptions of different types of masses. It begins with an introduction about pancreatic cancer statistics and risk factors. It then classifies pancreatic masses into endocrine tumors, exocrine tumors, cystic tumors, and metastatic tumors. The majority of the document provides detailed descriptions and ultrasound images of various masses, including pancreatic adenocarcinoma, focal pancreatitis, pseudocysts, cystic tumors, and endocrine tumors. It concludes by noting ultrasound continues to be useful but CT and MRI are more accurate for pancreatic evaluation.
1. The document discusses various types of pancreatic cysts including pseudocysts, congenital cysts, and neoplastic cystic tumors.
2. It outlines benign cystic neoplasms like serous cystadenomas and malignant mucinous cystic neoplasms.
3. Pancreatic ductal adenocarcinoma is discussed as the fourth leading cause of cancer death which often has KRAS and p16 mutations and a desmoplastic response.
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Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Film vocab for eal 3 students: Australia the movie
Cystic neoplasms of the pancreas 2007
1. Gastroenterol Clin N Am 36 (2007) 365–376
GASTROENTEROLOGY CLINICS
OF NORTH AMERICA
Cystic Neoplasms of the Pancreas
Michael P. Federle, MDa,*, Kevin M. McGrath, MDb
a
Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street,
Suite 3950, Pittsburgh, PA 15213, USA
b
Division of Gastroenterology, University of Pittsburgh Medical Center, 200 Lothrop Street,
1255 Scaife Hall, Pittsburgh, PA 15213, USA
W
ith the increased use of sophisticated imaging, particularly com-
puted tomography (CT), cystic masses in the pancreas are being
recognized with greater frequency. Several recent review articles
serve as an introduction to the clinical and imaging features of these masses
[1–4]. Although imaging alone may not provide a specific diagnosis in many
cases, a combination of imaging characteristics, clinical presentation, and judi-
cious use of additional procedures, such as cyst aspiration, allows appropriate
management.
This article presents the approach to the most commonly encountered pan-
creatic cystic masses that the authors employ at the University of Pittsburgh
Medical Center. Variations on this approach are to be expected, based on sev-
eral factors, including the availability of sophisticated imaging equipment and
personnel.
ETIOLOGY OF CYSTIC PANCREATIC MASSES
Pancreatic cystic masses may be the result of congenital, inflammatory, or neo-
plastic processes, as listed in Box 1 and Table 1 [5]. Some of these, such as an-
aplastic carcinoma, cystic teratoma, and hydatid disease, will be considered too
rare to warrant further discussion in this article. Intraductal papillary mucinous
neoplasm is considered important enough to discuss in a separate article of this
issue.
Congenital
‘‘True’’ cysts of the pancreas are those that are neither neoplastic nor the result
of prior inflammation. These are rare and cannot be distinguished from other
cystic masses except for the presence of an epithelial lining [6]. Congenital cysts
are usually single and small (1–2 cm), although larger symptomatic cysts have
been reported in children.
Multiple pancreatic cysts may be encountered in several syndromes and mul-
tisystem disorders, including autosomal dominant polycystic disease, cystic
*Corresponding author. E-mail address: federlemp@upmc.edu (M.P. Federle).
0889-8553/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.gtc.2007.03.014 gastro.theclinics.com
2. 366 FEDERLE & MCGRATH
Box 1: Cystic pancreatic masses
Congenital
True (epithelium-lined) cyst
Syndromes causing multiple cysts
Autosomal dominant polycystic disease
von Hippel-Lindau
Cystic fibrosis
Inflammatory
Pseudocyst
Pancreatic abscess
Hydatid cyst
Neoplastic
Benign
Serous (microcystic) cystadenoma
Cystic teratoma
Lymphoepithelial cyst
Malignant or potentially malignant
Mucinous cystic neoplasm
Solid and papillary epithelial neoplasm
Other (tumors that may have a cystic component)
Intraductal papillary mucinous neoplasm (IPMN)
Islet cell tumor
Anaplastic carcinoma
Metastases to pancreas (eg, ovarian cystadenocarcinoma)
fibrosis, and von Hippel-Lindau disease. The pancreatic cysts are of no clinical
concern in these settings, and differential diagnosis is generally not a problem.
In polycystic disease, family history and the presence of cysts in other organs
are diagnostic. In cystic fibrosis, the pancreas contains not only cysts but also
fatty replacement of the pancreatic parenchyma. In patients who have von Hip-
pel-Lindau disease, solid neoplasms develop in the brain, spinal cord, kidneys,
and adrenals. These patients are also prone to developing pancreatic cysts and
serous (microcystic) cystadenoma.
Inflammatory
A pseudocyst is the result of acute or chronic pancreatitis, or pancreatic trauma
(especially in children). A pseudocyst is usually regarded as the most common
etiology of a symptomatic pancreatic cystic mass. This ‘‘cyst’’ lacks an epithelial
3. CYSTIC NEOPLASMS OF THE PANCREAS 367
Table 1
General characteristics of pancreatic cystic lesions
Fluid
Morphology Cytology CEA characteristics
Serous Microcystic Small, cuboidal Low or absent Thin, clear
cells without
mucin
Mucinous Macrocystic, Mucinous Moderately Clear, mucoid,
usually septated epithelial cells increased viscous
Malignant Mural nodularity, Malignant Markedly Clear, mucoid,
septation mucinous increased viscous
epithelial cells
Pseudocyst Thin walled, usually Inflammatory Low Thin, dark
nonseptated cells
Abbreviation: CEA, carcinoembryonic antigen.
lining, is walled off by fibrous and granulation tissue, and contains fluid that
comprises pancreatic juice and variable amounts of necrotic debris and hemor-
rhage. Pseudocysts should be distinguished from fluid collections in pre-exist-
ing spaces, such as the lesser sac, that develop and resolve rapidly following
an attack of acute pancreatitis.
Imaging characteristics of a mature pseudocyst include near water-attenua-
tion fluid contents and a thin wall (rarely with curvilinear calcification). Less-
mature cysts have complex fluid and inflammatory infiltration of adjacent
structures such as the gastric wall and mesenteric fat (Fig. 1A). Septations
are uncommon, and enhancing mural nodules are absent. Pseudocysts usually
show a fairly rapid (days to weeks) evolution in size, unlike cystic neoplasms.
CT and MR generally show ancillary findings that help to establish the diag-
nosis of pseudocysts, such as signs of acute or chronic pancreatitis (inflamma-
tory infiltrates, ductal dilation, calcifications, and so forth) (Fig. 1B, C).
Cyst contents are generally thin fluid (unless grossly infected) that may look
like a cola beverage. Analysis shows an elevated amylase level (often >10,000
IU) that is diagnostic. However, mature noncommunicating pseudocysts may
lose amylase activity with time.
Pseudocysts generally take 4 to 6 weeks to develop a fibrous wall. Even ma-
ture pseudocysts may resolve spontaneously, often by erosion into the stomach
or bowel, and do not require intervention except for complications such as in-
fection, hemorrhage, or persistent obstruction of bowel or bile ducts. Interven-
tion is also required for persistent symptomatic cysts causing abdominal pain
and/or early satiety.
For symptomatic pseudocysts, management options include percutaneous
drainage, endoscopic drainage (transpapillary or transmural), or surgical drain-
age (cyst enterostomy). An experienced multidisciplinary team, taking into ac-
count patient wishes, ductal anatomy, and surgical risk, best makes
management decisions.
4. 368 FEDERLE & MCGRATH
Fig. 1. Fifty-six-year-old man who has a pancreatic pseudocyst. (A) Endoscopic ultrasound im-
age shows a spherical mass with a thin but measurable wall (between cursors) and a fluid-
debris level (arrow) in its dependent portion. (B) A CT scan performed 2 months later shows
decrease in size of the pseudocyst (arrow), a thin wall, and near-water-attenuation contents.
(C) The body-tail segment of the pancreas (arrow) is atrophic and the pancreatic duct is di-
lated, indicating chronic pancreatitis.
A pancreatic abscess is generally the result of severe acute pancreatitis and is
usually not a diagnostic problem. Infected pancreatic necrosis is a dreaded com-
plication of necrotizing pancreatitis and would not be confused with a cystic
neoplasm, based on the clinical presentation.
Benign Neoplasms
Cystic teratoma
Cystic teratoma occurs rarely in the pancreas. Imaging evidence of liquid fat
plus calcification and soft tissue may allow preoperative diagnosis.
Lymphoepithelial cyst
Lymphoepithelial cyst is another rare pancreatic tumor with imaging character-
istics (septated cystic mass in the body/tail segment) that often cannot be distin-
guished from cystic neoplasm (see later discussion) [7].
Serous (microcystic) cystadenoma
Serous (microcystic) cystadenoma is an uncommon tumor that typically occurs
in elderly women, with a female/male ratio of 1.5–4.5:1. The median age at
5. CYSTIC NEOPLASMS OF THE PANCREAS 369
diagnosis is approximately 70, and 80% of reported cases have been in patients
over the age of 60 [8–10].
Serous microcystic adenomas occur with increased frequency in patients
who have von Hippel-Lindau disease. Even in patients who do not have other
features of von Hippel-Lindau disease, similar genetic mutations are found in
most patients who have serous cystadenomas.
The typical imaging appearance of a serous cystadenoma is that of a sponge
or honeycomb, with innumerable tiny cystic spaces separated by thin septa
(Fig. 2A). The septa may coalesce into a central scar that may calcify. The small
size of the cysts and the numerous septa may cause the mass to appear solid on
imaging. Thin-section, contrast-enhanced CT or MR allows confident diagno-
sis in 20% to 30% of cases [10]. The septa and peripheral capsule of this well-
circumscribed tumor show brisk contrast enhancement. MR shows these
features as well as CT. In addition, the fluid content of the mass may be more
evident on MR as low signal (dark) on T1-weighted images, and high signal
(bright) on T2-weighted images.
A macrocystic variant of serous cystadenoma has been reported by several
groups of investigators [11–13]. Rather than having innumerable tiny cysts,
these are characterized by a single cystic mass with or without one or more
thin septa. This variant may be difficult to distinguish from a mucinous cystic
tumor. The serous mass is favored by having a thin nonenhancing wall, a lob-
ulated surface, and presence within the pancreatic head. Cyst aspiration is re-
quired for further evaluation.
Endoscopic ultrasonography (EUS) is now frequently employed for further
evaluation of cystic lesions discovered by cross-sectional imaging. EUS evalu-
ation (typically at 5 MHz) provides high-resolution imaging that highlights
the sponge-like or honeycomb appearance of the microcystic serous cystadeno-
ma (Figs. 2B and 3A, B). The macrocystic variant may mimic a mucinous
Fig. 2. Eight-two-year-old woman who has a serous microcystic adenoma. (A) A contrast-
enhanced CT scan shows a large spherical mass within the pancreatic head, having an ap-
pearance of a sponge, with innumerable tiny cystic spaces separated by thin, enhancing
septa. (B) EUS confirms the innumerable tiny cystic spaces and septa. The patient had minimal
symptoms related to the mass, and no surgery was performed.
6. 370 FEDERLE & MCGRATH
Fig. 3. Seventy-three-year-old man who has serous microcystic adenoma discovered on CT
evaluation of an abdominal aortic aneurysm. (A) Contrast-enhanced CT shows a multicystic
mass (arrow) in the pancreatic head. (B) EUS shows multiple small cystic spaces separated
by thin septa. A fine needle aspiration needle (arrow) was inserted and yielded thin fluid
with glycogen-rich cuboidal cells.
cystic neoplasm. Serous adenomas may also have few cystic spaces (‘‘oligocys-
tic’’), and these may mimic side branch intraductal papillary mucinous neo-
plasm. EUS-guided cyst aspiration can prove helpful in this situation. The
fluid content of macro- and microcystic serous tumors is thin and nonviscous.
Glycogen-rich cuboidal epithelial cells, when seen in the cyst aspirate, are diag-
nostic [14]. The carcinoembryonic antigen (CEA) level, which is the most ac-
curate tumor marker to diagnose a mucinous cystic neoplasm [15], is low or
undetectable. The authors currently only aspirate the macrocystic or oligocys-
tic variants to differentiate them from mucinous lesions. They consider the
sponge-like or honeycomb appearance of the microcystic variant pathogno-
monic at EUS and, therefore, no longer perform fine needle aspiration
(FNA) in this situation.
Serous cystadenomas are invariably benign and usually cause minimal
symptoms unless they attain sufficient size to compress upper abdominal con-
tents. Notably absent are any signs of invasion of blood vessels or ducts.
Confident diagnosis of a serous cystadenoma may be challenging but is im-
portant, because these are benign tumors that occur in elderly patients and of-
ten are best managed without surgery unless the patient has substantial
symptoms, such as pain, early satiety, or jaundice.
Malignant or Premalignant Neoplasms
Mucinous cystic neoplasm (mucinous cystadenoma and cystoadenocarcinoma)
Mucinous cystic neoplasms are being diagnosed with considerable frequency
that, in the authors’ experience, exceeds the ‘‘1% of all pancreatic malignan-
cies’’ figure that has been cited in prior studies and reviews. In the authors’
practice, mucinous cystic neoplasms are encountered more frequently than
pseudocysts, further supporting other centers’ experiences that these are now
the most common pancreatic cysts [4].
7. CYSTIC NEOPLASMS OF THE PANCREAS 371
Mucinous cystic neoplasms tend to occur in a younger age group with
a marked female predominance of approximately 80% [1,2,4,9]. Peak incidence
is in the 6th decade, but it is not rare to diagnose these in women as young as
35 years old. Unlike serous tumors, approximately 70% to 95% of mucinous
cystic tumors occur in the pancreatic body and tail segments.
Mucinous tumors are hypovascular, well-circumscribed masses with a wall
of measurable thickness that is lined by tall, mucin-producing columnar cells
and ‘‘ovarian-type stroma,’’ which is now considered a required feature for
confident diagnosis of mucinous cystic neoplasms [16–18]. The mass is gener-
ally unilocular or divided into fewer than six cystic spaces by septa (Fig. 4A, B).
The septa and peripheral wall may calcify, said to occur in 10% to 25% of cases
[16,18]. The mass may displace but usually does not obstruct the pancreatic
duct.
Mucinous cystic neoplasms should be considered malignant or premalig-
nant. The World Health Organization has classified the pathologic spectrum
of mucinous cystic neoplasms using three dysplastic grades: (1) adenoma (mu-
cinous cystadenoma), (2) borderline (mucinous cystic tumor—borderline), and
(3) carcinoma in situ (mucinous cystadenocarcinoma—noninvasive). An inva-
sive mucinous cystadenocarcinoma category exists, representing truly invasive
cystadenocarcinomas [5]. Any imaging evidence of mural nodularity, enhance-
ment or calcification, or ductal obstruction should be interpreted as suggestive
of malignancy.
The mucinous content of these tumors is suggested by higher than water at-
tenuation on CT and variable signal intensity (different than ‘‘simple’’ fluid) on
MR, reflecting the proteinaceous nature of the fluid. This is confirmed with
needle aspiration of the cyst contents, generally as part of the evaluation
with EUS (Fig. 5A, B). EUS also allows high-resolution imaging of the cyst
wall and may depict clues, such as mural nodularity, more readily than CT
Fig. 4. Forty-seven-year-old woman who has a mucinous cystic neoplasm (cystadenoma)—-
surgically proven. (A) Contrast-enhanced CT shows a spherical mass (arrow) arising from
the tail of the pancreas. A thin septum is visible near the dependent wall of the cyst. (B) EUS
demonstrates the cystic mass. The septum (arrow) and debris or mural nodularity along the de-
pendent wall are more evident than on CT.
8. 372 FEDERLE & MCGRATH
Fig. 5. Sixty-one-year-old man who has a mucinous cystic neoplasm (cystoadenocarcinoma)—-
surgically proven. (A) Contrast-enhanced CT shows a cystic mass (arrow) in the neck of the pan-
creas, immediately adjacent to the splenic vein. The mass has a detectable wall but no obvious
mural nodularity. (B) EUS shows a thick-walled cystic mass (arrow) just ventral to the splenic
vein (block arrow). The FNA needle is seen and aspiration yielded thick mucinous fluid with
an elevated CEA level.
or MR. True mass components or mural nodules involving the cystic tumor
can be accurately targeted by way of EUS-FNA for malignant cytologic confir-
mation. In the absence of a solid component, EUS-guided cyst aspiration is per-
formed for diagnostic purposes. Cyst fluid is slightly viscous to thick and
mucoid. The authors have rarely encountered mucinous cystadenomas with
a thin serous aspirate. As cyst aspirate cytology suffers from poor sensitivity
due to the paucicellular nature of the sample [2,4], cyst fluid tumor markers
play an important diagnostic role. Cyst fluid CEA level is the most accurate
tumor marker for diagnosis of a mucinous cystic neoplasm, with a diagnostic
accuracy of 79% when levels are greater than 192 ng/mL [2].
Cyst fluid CEA level, unfortunately, cannot predict the presence or absence
of malignancy. As the cellular content of cyst fluid aspirates is frequently sub-
optimal, it was hypothesized that cyst epithelial cells shed their DNA into the
fluid during cell turnover. As pancreatic carcinogenesis is characterized by the
accumulation of genetic defects, these mutations should be detectable through
cyst fluid DNA analysis. Additionally, an evolving or frankly malignant cyst
should have a higher DNA content due to a higher cell turnover rate, and
more mutations should be present. To test this hypothesis, molecular analysis
of EUS-guided cyst fluid aspirates was performed by way of polymerase chain
reaction amplification of individual microsatellite markers associated with pan-
creatic carcinogenesis, along with direct sequencing of the k-ras-2 gene [15].
The DNA amount within the fluid (reported as optical density), number of mu-
tations, and temporal sequence of mutations were shown to accurately predict
the presence of malignancy. A first-hit k-ras mutation followed by an allelic loss
was highly predictive of malignancy. Although based on this small preliminary
experience, molecular analysis may serve as an adjunct test in the evaluation of
cystic pancreatic lesions and is currently being evaluated in a multicenter study.
9. CYSTIC NEOPLASMS OF THE PANCREAS 373
Although mucinous cystic tumors are to be considered premalignant, the
natural history of these tumors and true malignant risk are largely unknown.
Therefore, surgical resection is not necessarily required in all patients. Manage-
ment decisions should be based on many factors including the characteristics of
the tumor itself, the general age and condition of the patient, and the availabil-
ity of surgical expertise. Factors that would favor a more conservative ap-
proach would include advanced patient age or comorbidity; a pancreatic cyst
that was small, thin-walled, and noninvasive; a low cyst-fluid CEA level; and
a molecular analysis that revealed a low amount of poor-quality DNA with
an absence of mutations. A more aggressive approach is often warranted in
younger patients who have fewer comorbid factors, a larger or symptomatic
cyst, and the availability of a surgeon experienced and expert at partial pancre-
atic resection. Frankly malignant cysts, when diagnosed, should be surgically
resected if the patient is an acceptable operative candidate.
Solid and papillary epithelial neoplasm
This is a rare tumor of low malignant potential that has been reported under
various names including solid and pseudopapillary neoplasm, and solid and
cystic tumor. Solid and papillary epithelial neoplasm has a predilection for
young women, with over 90% of cases being reported in women under the
age of 35, usually in non-Caucasians (Asian or African-American) [19]. The tu-
mor is slow growing and may cause little or no discomfort until large.
Because of its indolent nature, solid and papillary epithelial neoplasm is often
diagnosed when it has attained considerable size (on average, >10 cm). It is
a hypovascular well-circumscribed mass, most often located in the pancreatic
body/tail segments (Fig. 6A–C). Depending on the extent of necrosis and hem-
orrhage within the tumor, a solid and papillary epithelial neoplasm may appear
almost completely cystic or solid, though a poorly enhancing mass with central
and scattered necrosis is the most characteristic finding.
EUS-FNA can generally provide an accurate preoperative diagnosis, which
can then direct the surgical approach (open or laparoscopic resection) [20].
Lymph node and liver metastases occur rarely and late in the disease. Com-
plete surgical excision is generally possible and curative.
Cystic islet cell tumor
Pancreatic neuroendocrine (islet cell) tumors are usually hypervascular solid
masses and may be benign or malignant. Those that produce excessive
amounts of active polypeptide hormones, such as insulin or glucagon, are gen-
erally diagnosed while the tumors are small (1–3 cm). Tumors that are ‘‘non-
functional’’ are more likely to be diagnosed after they have attained large size;
although in the authors’ experience, smaller incidental nonfunctioning tumors
are being detected, given increased use of abdominal imaging modalities
[21–23].
Rarely, an islet cell tumor may be largely cystic (Fig. 7A, B). By imaging,
these cannot be distinguished from other pancreatic cystic masses, especially
if the mass is less than 2 cm in diameter. The diagnosis may be suggested
10. 374 FEDERLE & MCGRATH
Fig. 6. Twenty-two-year-old woman who has a solid and papillary epithelial neoplasm. (A)
Contrast-enhanced CT shows a mass (arrow) arising from the pancreatic tail. Peripheral calci-
fication and enhancing nodules are seen along with cystic or necrotic areas. (B) EUS shows
a complex cystic mass with peripheral calcifications (arrow). (C) Photograph of resected
mass shows an encapsulated tumor with foci of cystic necrosis and solid tumor.
by evidence of hypervascular liver metastases or clinical signs or symptoms
such as palpitations, tremor, and headache (hypoglycemia due to an
‘‘insulinoma’’).
EUS imaging typically reveals a thick-walled unilocular cyst, and EUS-FNA
can provide a definitive diagnosis on the basis of cytologic immunostaining pat-
terns. Surgical resection is the treatment of choice.
SUMMARY
Pancreatic cystic lesions represent an increasingly common diagnostic and ther-
apeutic challenge. Many cystic masses are pancreatic pseudocysts, and this di-
agnosis is usually made readily by clinical history and imaging findings of
a unilocular pancreatic or peripancreatic mass with associated findings of acute
or chronic pancreatitis. CT and MR allow accurate depiction of the morphol-
ogy of cystic pancreatic masses, and when in doubt, EUS-FNA can provide di-
agnostic information based on fluid viscosity, CEA and/or amylase level, and
molecular analysis. In patients who have large, symptomatic, or complex cystic
neoplasms and are suitable candidates for major surgery, preoperative
11. CYSTIC NEOPLASMS OF THE PANCREAS 375
Fig. 7. Sixty-six-year-old man who has a cystic islet cell tumor. (A) Contrast-enhanced CT
shows a small mass (arrow) in the pancreatic body that is mostly cystic, with a briskly enhanc-
ing wall. (B) EUS confirms the small mass (arrow) with a central cystic space and a thicker wall
than was evident on CT.
evaluation by other imaging tests or cyst aspiration may be unnecessary. For
lesions that are small, asymptomatic, or occur in patients who have high surgi-
cal risk, further evaluation with endoscopic ultrasonography is often useful.
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