Diagnosis and Treatment of Cystic Pancreatic Tumors Mohammad Al–Haddad, Max C. Schmidt, Kumar Sandrasegaran, John Dewitt  Clinical Gastroenterology and Hepatology  Volume 9, Issue 8, Pages 635-648 (August 2011) DOI: 10.1016/j.cgh.2011.03.005 Copyright © 2011 AGA Institute Terms and Conditions

Figure 1 Serous cystadenoma (SCA). (A) A 71-year-old female with typical CT appearance of a 6-cm multiseptated mass (arrow) with honeycomb appearance and central calcifications. (B) A characteristic endoscopic ultrasound appearance of a microcystic serous cystadenoma in the head of the pancreas in an asymptomatic 65-year-old female patient. The lesion contains multiple small cysts separated by thin septa (curvilinear echoendoscope examination performed from the duodenal bulb). (C) A cross-section from a resected microcystic serous cystadenoma from a symptomatic male patient. A fibrous core is surrounded by microcysts. (D) Dense, fibrous stroma (blue arrows) separate low cuboidal cells (red arrows) with clear cytoplasm of a serous cystadenoma. No cellular atypia was noted (H&E, magnification 400×). Clinical Gastroenterology and Hepatology 2011 9, 635-648DOI: (10.1016/j.cgh.2011.03.005) Copyright © 2011 AGA Institute Terms and Conditions

Figure 2 Mucinous cystic neoplasms (MCN). (A) A 31-year-old female with MCN. Despite a large size lesion (arrow) arising from the tail, it was benign without atypical cells. Note large locules and mild ascites. Multiple cystic spaces with variable thickness septations are apparent (arrow) and generally considered a risk of malignancy. Peripheral calcifications (arrowheads) within the septa are noted in up to 15% of patients. (B) A 51-year-old female with MCN. T2 weighted MRI shows typical location and pauci-locular appearance (arrow). No malignancy on surgical pathology. (C) EUS findings in a middle-age female patient with an MCN in the body of the pancreas. A cyst wall is present and few intracystic nodules arising from the wall (arrow) could represent a solid lesion or mucous (radial echoendoscope examination performed from the gastric body). (D) Gross surgical specimen in a patient with MCN. Multiple cystic compartments filled with mucin (arrows) are noted. No malignancy was detected in this specimen. (E) Histology photomicrograph from a resected MCN lesion: columnar epithelium (blue arrow) with unique spindle cell stroma (yellow arrow) similar to ovarian stroma. This ovarian stroma-like appearance is the pathologic hallmark of MCN (H&E, magnification 400×). Clinical Gastroenterology and Hepatology 2011 9, 635-648DOI: (10.1016/j.cgh.2011.03.005) Copyright © 2011 AGA Institute Terms and Conditions

Figure 3 Intraductal papillary mucinous neoplasms (IPMN). (A) A 69-year-old female with mixed IPMN presenting with recurrent acute pancreatitis. CT scan shows a 4-cm cystic mass with mural nodules (red arrow). (B) MRCP in a 55-year-old asymptomatic male patient shows main duct dilation in head (blue arrow) and <3 cm side branch cystic masses (red arrow). The patient underwent resection; surgical pathology showed high-grade dysplasia without invasive malignancy. (C) The major papilla in a 67-year-old male with main duct IPMN on side-view endoscopic examination. Mucin is seen exuding from the papillary orifice. (D) Endoscopic retrograde cholangiopancreatography appearance of a dilated main pancreatic duct in a patient with main duct IPMN. Filling defects are seen within the duct and are consistent with mucin. (E) EUS findings of a 60-year-old female patient with a dilated and ectatic main pancreatic duct in the body and tail who presented with steatorrhea and weight loss. The patient underwent distal pancreatectomy that demonstrated main duct IPMN with focal minimally invasive adenocarcinoma (curvilinear echoendoscope examination performed from the gastric body). (F) Surgical specimen in a patient with main duct IPMN in the body and tail of the pancreas. A cross-section in the pancreas showed atrophic parenchyma and a dilated main duct. The spleen was also removed en bloc during distal pancreatectomy. (G) Surgical specimen from pancreaticoduodenectomy in a patient with main duct IPMN. Second portion of the duodenum (D) and the ectatic main duct (between arrow) measuring 1 cm are shown. (H) Histology from a resected IPMN side branch lesion: papillary projections (black arrows) covered by columnar epithelium with clear cytoplasm (red arrow) and septa in mucin-filled lacuna (green arrow) (H&E, magnification 100×). Clinical Gastroenterology and Hepatology 2011 9, 635-648DOI: (10.1016/j.cgh.2011.03.005) Copyright © 2011 AGA Institute Terms and Conditions

Figure 4 Solid pseudopapillary tumor (SPT). (A) A CT scan of the abdomen in a young female patient demonstrating a solid pseudopapillary tumor slightly compressing the portal venous confluence under the neck and body of the pancreas. (B) EUS appearance of the solid pseudopapillary tumor in the same patient. The tumor is seen to abut the portal vein (PV) and encase the splenic artery (SA) (curvilinear echoendoscope examination performed from the gastric body). (C) Core biopsy histology of a pseudopapillary tumor. Myxoid stroma and branching papillae are seen (H&E, magnification 400×). Clinical Gastroenterology and Hepatology 2011 9, 635-648DOI: (10.1016/j.cgh.2011.03.005) Copyright © 2011 AGA Institute Terms and Conditions

Figure 5 Suggested EUS and imaging based algorithm for the management of mucinous CPTs. Clinical Gastroenterology and Hepatology 2011 9, 635-648DOI: (10.1016/j.cgh.2011.03.005) Copyright © 2011 AGA Institute Terms and Conditions