1. ERIC TRAWICK EUS CONFERENCE JUNE 2011 Pancreas Cyst

2. Overview JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299- 309. Pancreatic cysts are being diagnosed with increasing frequency due to the widespread use of cross-sectional imaging  Estimated prevalence of 1% in the general population  Up to 40% are asymptomatic Pancreatic cysts can be divided into 2 broad categories  Neoplastic  Classified by the type of epithelium lining the cyst  Non-neoplastic  Pseudocyst  Non-neoplastic pancreatic cysts (rare) Include retention cyst & True cysts Retention cysts Mucinous non-neoplastic cysts Lymphoepithelial cysts Accurate cyst categorization is needed for proper management

3. Overview JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299- 309. Rarely, solid pancreatic tumors may present as pancreatic cyst – Islet cell tumor Pancreatic cystic lesions are usually an isolated finding, but are associated with both von Hippel- Lindau disease and ADPKD – Pancreatic cyst are present in up to 70% of patients with von Hippel-Lindau disease – Approximately 10% of patients with ADPKD have pancreatic cyst

4. Cross-sectional Imaging JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299- 309. Unreliable means of diagnosis when used alone Up to 40% of serous and mucinous lesions are misdiagnosed as pseudocysts Diagnostic accuracy of CT is reported between 20- 83% MRI is equivalent or slightly better than CT for diagnosis of cystic pancreatic lesions As expected MRCP is superior to CT in defining ductal anatomy

5. Journal of Computer Assisted Tomography. 1999 23(6):906-912.

6. Indication for EUS World J Surg (2008) 32:2028–2037 No hard and fast rules Will EUS change management?  Symptomatic or worrisome lesions are usually resected without need for EUS &/or FNA Is there a clear history of pancreatitis and a new cystic lesion?  If obviously a pseudocyst then don’t need EUS EUS +/- FNA is indicated to further assess and categorize cystic pancreatic lesions

7. EUS Morphology JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299- 309. Cyst wall – Thick vs. thin Solid component Associated with malignancy Septations – Micro vs. macrocystic Ductal abnormalities Main duct vs. side duct Number of cyst Lymphadenopathy EUS morphology can correctly differentiate mucinous from non-mucinous cystic lesions approximately 50% of the time

10. Normal Pancreas— EUS image of the normal pancreas (P, outlined by short arrows) with a finely granular echoic pattern that is characteristically very homogeneous. A part of the normal diameter (1 mm) pancreatic duct (pd) is seen in the tail. Upper pole of the kidney (K) is also visible. (Magnification range scale = 9 cm).

11. JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299- 309.

12. Examples of Morphology JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299- 309.

16. FNA & Fluid Analysis Cytology  High specificity, low sensitivity Mucin  High specificity, low sensitivity Amylase/Lipase  Elevated in Pseudocyst & IPMNs  Low in SCN & MCN CEA  Most accurate test to distinguish mucinous from non-mucinous cyst DNA analysis  Mixed data when compared to CEA

17. World J Surg (2008) 32:2028–2037

18. Cyst Fluid Analysis ASGE Guidelines 2005

19. Application Aliment Pharmacol Ther. 2010 Jan 15;31(2):285- 94 A retrospective analysis of 153 pts undergoing EUS for pancreatic cyst between 1996 to 2007 Clinical history, EUS characteristics, cytology, tumor markers and surgical histology were collected Predictors of malignancy were determined by univariate and multivariate analysis

20. Application Gastroenterology. 2004 May;126(5):1330-6 Prospective study of 341 pts found to have a pancreatic cystic lesion >10 mm on abd imaging Exclusion criteria included: abnormal coags/platelets &/or an abscess EUS was performed looking at morphology, cyst fluid cytology, and cyst fluid tumor markers (CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3)

21. Gastroenterology. 2004 May;126(5):1330-6

23. Summary No single test or imaging modality can reliably differentiate cyst type Composite data is needed  Clinical features of the patient  Cross-sectional imaging  Tumor markers  EUS with cyst fluid analysis

24. http://daveproject.org/pancreas-chronic-pancreatitis- with-eus-fna-of-pseudocyst/2004-05-07/ http://daveproject.org/pancreas-chronic-pancreatitis- with-eus-fna-of-pseudocyst/2004-05-07/ http://daveproject.org/pancreas-eusfna-of-ipmn-with- malignant-transformation/2007-11-13/ http://daveproject.org/pancreas-eusfna-of-ipmn-with- malignant-transformation/2007-11-13/ ASGE Guidelines 2005

25. http://daveproject.org/pancreas-serous-cyst-with-bleeding/2009-04- 23/ http://daveproject.org/pancreas-serous-cyst-with-bleeding/2009-04- 23/ http://daveproject.org/pancreas-serous-cystadenoma-with-fna/2007- 11-13/ http://daveproject.org/pancreas-serous-cystadenoma-with-fna/2007- 11-13/ http://daveproject.org/eus-fna-of-solid-pseudopapillary-tumor/2011- 02-21/ http://daveproject.org/eus-fna-of-solid-pseudopapillary-tumor/2011- 02-21/ ASGE Guidelines 2005

26. GASTROENTEROLOGY 2005;128:463–469