DR Santosh Narayankar Gastroenterologist yashoda hospital hyderabad

1. Cystic Tumors Of
Pancreas

2. Uncommon
<10% of pancreatic neoplasm's
CT prevalence 3%
MRI prevalence 20%
Cumulative 40% in patients older than 70yrs
Increasing prevalence – attributed imaging

4. Types cystic tumors of pancreas
Serous Cystadenoma
32-39%
Mucinous Cystic
Neoplasm
10-45%
Intraductal Papillary
Mucimous Neoplasm
21-33%
Solid pseudopapllary
neoplasm
<10%
Cystic Endocrine
Neoplasm
<10%
Ductal
Adenocarcinoma with
Degeneration
<1%
Acinar cell
Cystadenocarcinoma
<1%

5. Serous Cystadenoma 32- 39%
Mucinous Cystic Neoplasm 10-45%
Intraductal Papillary Mucinous
Neoplasm 21-33%
Solid Pseudopapillary
Tumor <10%
Cystic endocrine
neoplasm <10%
DACD <1%
ACAC
<1%

7. Mucinous Cystic Neoplasm
Less common than SCN & IPMN
Thick wall and thick fluid
Mucus or hemorrhagic material
Occasional septae
All cases to be considered as premalignanent
Female > Male 20:1
Body and tail >95%
50years mean age

8. On MRCP – No communication with MPD
Histology – Ovarian stroma
Cyst fluid - Thick mucoid material ,
Low amylase,
Elevated CEA,
Mucinous epithelial cells on cytology.
Surgical resection in all.

9. CT showing MCN EUS showing
septations

10. Serous Cystadenoma
Predominantly benign tumours with little risk of
malignant behaviour.
Clinical Presentation - Incidental, rarely
abdominal pain or palpable mass .F>M,7th dcade.
Imaging- Micro cystic/honeycomb appearance
typical. Oligo cystic appearance less common
Cytology - Cuboidal cells stain positive for
glycogen.

11. Honey comb appearance

12. Malignant potential – No, or little
Treatment – Surveillance or No treatment
unless symptomatic.
Association – VHL Syndrome

13. IPMN
6th to 7th decade
F = M
Clinical presentation - Incidental, abdominal pain, pancreatitis,
symptoms or signs of malabsorption.
Imaging - Dilated main pancreatic duct or pancreatic duct
branches; solid component, if present may suggest malignancy.
Cytology- Positive for mucin, columnar epithelium with
variable atypia.

14. Malignant potential- Yes (MD-IPMN > BD-
IPMN)
Treatment - Resection for main duct IPMN
and resection or surveillance for branch duct
IPMN depending upon the clinical situation.
Prognosis – Excellent if adenoma
Poor if adenocarcinoma

15. CT
ERCP

16. Solid Pseudopapillary Neoplasm
F>M
4th Decade or less
Usually incidental, abdominal pain or palpable mass
Solid and cystic mass
Myxoid stroma
Malignant potential – yes
Resection

17. Evaluation Pancreatic Cystic
Neoplasm

18. Cystic
Lesion
Pseudo
cyst
Cystic
Neoplasm

19. Characteristics that favor Pseudo cyst
Lack of septae
Lack of loculations
No Solid components
No Cyst wall calcifications
Fluid amylase level high
Communication with MPD
Lack epithelial lining
Antecedent h/o acute or chronic pancreatitis.

20. Tumors with Malignant Potential
•MCN
•IPMN
•SPT
•Cystic islet cell tumor

21. Imaging methods used
CT with IV
contrast
MRI with
IV
contrast
and MRCP
EUS + FNA PET CT

22. What are the initial imaging tests to
evaluate a pancreatic cyst?
EUS+FNA
MRI with MRCP

23. FNA Analysis

24. Do incidental/asymptomatic pancreatic
cysts need to be evaluated?
• most cysts
detected today
are
asymptomatic
and more than
half of these are
premalignant
(MCN and IPMN).
Yes,

25. What if the asymptomatic cyst is very
small, say 5 mm?
A reasonable approach
may be to repeat cross-
sectional imaging in a
year to assess for change.

26. Do all cystic neoplasm's have to be
evaluated with EUS?
• In some cases, the
clinical and MRI findings
are sufficient to
diagnose the type of
cystic lesion with
confidence.
No,

27. Is EUS imaging alone all we need for the
evaluation of a pancreatic cystic lesion?
Cyst fluid needs to be evaluated with cytology and
tumour markers.
Determination of morphology based on EUS imaging is
not specific enough.
No

28. Should all cysts be aspirated?
No
In some situations aspiration is not indicated
Or may even be contraindicated.

29. Are all cysts occurring in the setting of
pancreatitis are pseudo cysts?
Only half of the cysts associated with pancreatitis
may be Pseudo cysts
IPMN may present with pancreatitis.
No

30. Should antibiotics be administered at
the time of cyst FNA?
•Broad spectrum
IV antibiotic (
quinolone) at
the time of cyst
aspiration
It is accepted
practice to
administer

31. If surgery is not
undertaken, how should
these lesions be
followed?

32. Cyst seen on imaging
>3cm and Positive
features on MRI
Repeat MRI in 1year
and biannualy to year 5 EUS +FNA
NO
YES

33. Repeat MRI in 1 year and Bi
annually to year 5
EUS +FNA
Concerning cytology
and positive features
YES
Consider
surgery
NO
N
O
Stop
Surveillance
+ve
changes

34. Surveillance after operation
No definite stop date.
2nd Yearly MRI
Dysplasia or Invasive disease

35. The use of cyst fluid KRAS to identify mucinous lesions
is highly specific (greater than 95%) and moderately
sensitive(45%).other GNAS DNA ,micro RNA.
Groups have used ethanol injection, in the
Ethanol Pancreatic Injection of Cysts (EPIC) trial
, as well as combination ethanol/paclitaxel
injection .Used in patients not fit for surgery.