Law panc cyst talk

1. Pancreatic cysts : patient evaluation
& the role of EUS
Joanna K Law, MD, MA(ed), FRCPC

2. © 2017 Virginia Mason Medical Center
Disclosures
Nothing to disclose

3. © 2017 Virginia Mason Medical Center
Objectives
• Recognize the different types of
pancreatic cysts
• Understand the risk of malignancy with
each type of cyst
• Understand the role of & methods for
surveillance
• Know about the role of EUS in
surveillance and management

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Pancreatic cysts
• Increased detection through improved
imaging & access
– 20% MRI studies – incidental finding*;
– in US, prevalence of incidental pancreatic cysts
2.6-13.5% of adults (higher in older
population)**
• Cystic tumors = 10-15% of all pancreatic
cancers
*Lee, KS AM J Gastroenterol 2010; 105:2079-84
** de Jong, K Gasroenterol Res Pract 2012

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Approaching cysts
• 3 questions:
– What type of cyst is it?
– Is the cyst malignant?
– What is the likelihood that the cyst will
become malignant?
• Evaluation, management +/-
surveillance

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Categorizing cysts
Nonneoplastic
Cystic neoplasms
Necrotic degeneration of solid tumors
Mucinous vs non-mucinous

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History
• Pancreatitis history
– history of pancreatitis, gallstone disease
or EtOH
– Can this be a pseudocyst
• Can pancreatitis be a complication of
the cyst
• Family history of pancreatic cancer

8. • Dedicated
pancreatic protocol
CT
• MRI should include
MRCP to determine
relationship of
cystic lesion to PD

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Imaging findings
Pseudocyst SCN MCN IPMN
Characteristi
c cyst
appearance
Unilocular
cyst
associated
with
evidence of
pancreatitis
Multiple
hypodense
cysts with a
fibrotic
central scar
Unilocular
cystic lesion
with
peripheral
calcification
Polycystic,
lobulated
margins
Communicati
on with PD
Occasionally No No Yes
Features
suggestive of
malignancy
Very rare Mural
nodules size
>4cm
Mural
nodules BD
IPMN lesion
>3cm
Main PD
dilation

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Imaging/ Radiology
Sainani, N. AJR Am J Roentgenol 2009; 193:722.

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Endoscopic ultrasound
• Complementary imaging technique for
assessment of the incidentally found
pancreatic cyst
– EUS does not demonstrate any difference in
sensitivity compared to MRI in diagnosis of
cystic pancreatic lesions*
• HOWEVER – EUS has advantage of ability
to perform needle aspiration of cyst
contents
Kim, Y. Am J Roentgenol 2010; 195:947

16. • EUS alone is
insufficient for
diagnosis of
mucinous cysts*
• Cytology useful for
certain cysts (SPN,
PNET)
Brugge WR. Gastroenterology. 2004: 126:1330.

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Typical cyst fluid analysis
Pseudocyst SCN MCN IPMN
Cyst fluid
cytology
Mainly inflam
cells
Glycogen
containing
cells
Mucin
producing
cells
Mucin
producing
cells
Cyst CEA <192ng/mL <5ng/mL >192 ng/ml >192 ng/ml
Cyst amylase >250 U/L <250 U/L <250 U/L <250 U/L

23. Is this cyst malignant?
• Predictors &
guidelines help
identify high risk/
worrisome lesions
• EUS superior to
radiology for
detection of
pancreatic cancer
during surveillance
period*
Kamata K. Endosocpy 2014; 46:22.

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Will this cyst be malignant?
• Dependent on the TYPE of cyst
• Natural history of cysts are not fully
understood

25. Serous cystic neoplasms
• Considered benign
lesions with very
low risk of
malignant
transformation*
• Symptoms
attributable to cyst
(pain, mass,
jaundice) more
likely in SCN >4cm
– Once >4cm, the
rate of growth is
faster
Strobel, O. Digestion. 2003; 68: 24-33

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Serous cystic neoplasms
Surgery is not necessary >4cm in
asymptomatic individuals
Surveillance is reasonable given that initial
cyst diagnosis is incorrect in up to 1/3
patients
– Can stop surveillance if stability is
demonstrated or patient is unfit for
intervention

27. Mucinous cystic neoplasms
• Almost exclusively
in women (>95%),
50s
• + risk of malignant
transformation
(17.5% in 1 series
showing HGD or
carcinoma)
• In the fit patient,
resection is
advocated
– Post resection, the
need for
surveillance is not
necessary if non
invasive disease
– Recurrence is 37-
83% in patients
with cancer
Crippa, S. Ann Surg 2008; 247:571-9

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More common on men; 7th decade
– Main duct  invasive carcinoma 50%
– Branch duct  invasive carcinoma 11%
– Mixed type
Intraductal papillary mucinous
neoplasms

29. IPMN - MD
• Main duct – high
incidence of
carcinoma –
surgical resection
recommended in
the fit patient
• Ongoing
surveillance post-
resection

32. IPMN - BD
• various guidelines
• surveillance vs
surgery
– Risk of surgery
– Risk of missing
progression during
surveillance
• EUS in larger
lesions (>2cm)
alternating with
cross-sectional
imaging

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34. © 2017 Virginia Mason Medical Center
SUMMARY
• Challenging to manage – we are
finding more
• No single modality (imaging, cyst
fluid) suffices for diagnosis but
rather, combined approach & when
appropriate, ongoing surveillance is
required

35. QUESTIONS?