1. Pancreas Cysts : What Do I Do in My Practice??
Santhi Swaroop Vege
Director Pancreas Group
Professor of Medicine
Mayo Clinic, Rochester

2. How Big Is the Problem??
25% of autopsies. 16% have atypical epithelium
2.6% of population undergoing CT
2.4% of MRIs for preventative exam
13.5% of MRIs in a teaching institution.

3. Simple Classification of Pancreas Cysts
Inflammaory – pseudocysts
Cystic neoplasms :
Serous cystadenoma
Mucinous cystic neoplasms (with ,without cancer)
IPMN (side-branch and main duct)
Degeneration of neuro-endocrine and adenocarcinoma
Solid papillary tumor (SPT)
Hamartoma, lymphocele, epithelial cysts

4. Common Facts about Pancreas Cysts
Symptomatic cysts – usually pseudocysts
Asymptomatic – neoplastic ( serous and mucinous cystadenoma, IPMN- main duct and side branch, solid papillary tumor, cystic degeneration of islet cell tumor)
Mucinous cysts ( IPMN and MCN) have malignant potential
Epithelial, simple, hamartomatous cysts are rare

5. Common Facts about Pancreas Cysts
Most of the cysts are asymptomatic and neoplastic
Cancer can occur in asymptomatic cysts too!
Pseudocysts are usually symptomatic and hx of acute or chronic pancreatitis
If present on the early CT scan in AP, then not usually pseudocyst but IPMN causing AP
Cystic neuro-endocrine tumors have enhancing wall on CT

6. Approach to Pancreas cysts
Clinical
Imaging : CT and or MRCP
EUS
FNA – CEA, amylase, cytology, mucin stain, string sign, glycogen stain
DNA analysis and mutations, Ca 19-9 ??
Tru-cut biopsy
Surgical excision

7. Cystic lesions of the pancreas
(Main duct IPMN)
(side-branch IPMN)
Solid Papillary Tumor
Cystic lesions of the
pancreas

8. Clinical Characteristics of Pancreas Cysts
Brugge WR, CGH 2008

9. Cross sectional imaging
SCA
MCN
IPMN
SPT
Gender (M:F)
1:3-4
1:9
1-2:1
1:10
Age
60-80
30-50
20-40
Cross sectional imaging
Location
Body/tail > head
Body/Tail
Head > body/tail
Even distribn.
Appearance
Multiple, small, calcifn.
Unilocular/
solitary
Irregular/
Polycystic/
multiple
Encapsulated/uni/multiloc./solid component
Malignancy
Very rare
> 3cm, mural nod.; eggshell calcifn.
MPD> 1cm; BD> 3cm; mural nod.
Occasional
Cyst fluid analysis
Mucin
Low
High -
CEA
< 5 ng/mL
> 192 ng/mL
> 192 ng/mL
Amylase
<250 U/L
>250 U/L

10. Imaging Facts of Pancreas Cysts
CT commonest imaging
MRCP becoming more popular : ductal communication, no radiation
1/3 of SCA classical findings ( bunch of grapes)
Egg shell and peripheral calcification bad

11. 66 yrs/F; Incidentally detected
28 yrs/F; Presented with RLQ abd. pain.

12. MCN

13. 49 yrs/F;
Early satiety, nausea, constant epigastric pain X 2 weeks
?? H/O acute pancreatitis 5 wks back
Amylase > 10,000 U/L
CEA- 428

14. Main Duct + Side Branch IPMN

15. IPMN CLASIFFICATION Main Duct Side branch Mixed component
Tanaka M Pancreas 2004:3:

16. IPMN CLASIFFICATION Invasive-Non invasive , Benign- Malignant
ADENOMA
BORDERLINE
Carcinoma in situ
Invasive carcinoma
NON INVASIVE
INVASIVE

17. Image Characteristics
ERCP

18. Image Characteristics
MRI

19. Image Characteristics
CT Scan

20. Image Characteristics
EUS

21. DIFFERENTIAL DIAGNOSIS

22. 22 yrs/F; Upper abdominal pain with early satiety (SPT)

23. SPT

26. Imaging Findings Associated with Malignancy
Brugge WR CGH 2008

27. Role of EUS > 1.5 cm cysts SCA with typical CT features not needed
Morphology, CEA, cytology
FNA cytology sensitivity poor ~ 50%
Tru-cut bx for SCA, MCN, malignant tumor
Ca 19-9, DNA and K-Ras not proven
High CEA, ca 19-9 not necessarily mean cancer

28. Algorithm For the Mananagement of Side-branch IPMNs
Brugge WR CGH 2008

29. Consensus indications for resection of branch IPMN
Symptomatic
Dilated main pancreatic duct
Size > 3 cm
Mural nodule
Malignant cytology

30. Treatment Recommendations
Most asymptomatic cysts observe
Resection for main duct IPMN, side branch IPMN meeting Sendai criteria, MCN,SPT
Resect cystic degeneration of malignant tumor
Enlarging SCA specially with bile duct or PD obstruction

31. Recent Concepts in Treatment
Many side-branch IPMNs can be observed
Size > 3 cms resection not necessary
SCA > 4cms resection
All MCNs may not need resection

32. 65-yr-old lady 3-4 loose stools for 2 years No loss of wt or appetite
No abdominal pain
No comorbidities

38. Based on CT appearence, what possibilities do you think?

39. EUS Vague mass in head ill-defined, 1.5cm
FNA – cells suspicious for adenocarcinoma
Surgery? Whipple or total?

40. Spleen –sparing Total Pancreatectomy
3.9 cm invasive grade 3 adenocarcinoma head with IPMN of entire pancreas with severe dysplasia
Peripancreatic invasion, cut margins free

41. 68-yr-old Patient with Breast Cancer in March 2005
CT showed large cystic lesion in body and tail dring breast cancer workup. Surgery done for breast
No abdominal symptoms at all and doing well
Presented to Mayo in Apr 2007 for opinion for pancreas cyst stable for 2 years on CT
Breast cancer for over 2 years controlled
Patient in good general condition

43. Cyst > 2 cm

45. Report of CT Scan
11X10X6 cm multicystic mass in body and tail. One cyst larger than 3 cms
Abuts splenic artery and vein and stomach but does not invade them
PD not dilated
Some cyst walls calcified
Possibly serous cystadenoma

46. Is there a need for EUS with without FNA with this CT report
Is there a need for EUS with without FNA with this CT report? Is this serous oligocystic adenoma?

47. SOA ( serous oligocystic adenoma) has some unilocular cysts > 2 cm and 6 or fewer cysts Difficult to distinguish from mucinous cystadenoma

48. EUS, FNA, Trucut Biopsy of Cyst
Multicystic lesion confirmed
No vascular involvement
Largest cyst 3 cm, calcified walls in some
CEA 0.5 ng/ml and amylase 27 U/L
Cytology acellular. Mucin stain negative
Biopsy : Serous cystadenoma

49. Does she need surgery? Does the size of the cyst matter, given all other findings?

50. Tumor Growth of Serous Cystadenoma
Median growth 0.6 cm / yr.
Greater growth in lesions > 4 cm in a study of 106 patients from Mass General Hospital
Resect those > 4 cm regardless of symptoms
Ann Surg 2005;242:413

51. 56-yr-old lady with 3 Months Epigastric Pain
Lipase 3-fold elevated
US, CT 3.6 cm cystic mass in head with mural nodule
Lap chole for biliary pancreatitis and pseudocyst
Gall bladder no stones
Severe pain continued, referred to Mayo

56. EUS
4.1 cm predominantly solid lesion with cystic areas and calcification
CEA 132, amylase 9600, serum Ca 19-9 nl
Cytology from nodule and cyst fluid negative

57. Ch Pseudocyst or MCN or SPN? Surgery or Endoscopic Drainage?

58. Surgery PP pancreatico-duodenectomy Path: MCN with low grade dysplasia
Pt did well

59. Summary Very common on imaging, asymptomatic Only 4 of them are common
Mucinous cysts can turn into cancer
Very few cysts require resection
Observation with CT or MR most of the time