1. Cystic lesion of pancreas
Chan Chi King
North District Hospital

2. The tumor, now the size of a small coconut , was a little above and to the left of the umbilicus, feeling like a tense cyst, & pulsating plainly form motion transmitted from the aorta. The dignosis of pancreatic cyst was made..
Ann Surg Aug;18(2):227-8

3. How common? Prevalence 0.21% to 24.3%
Ikeda M. et al 1994; Kimura W. et al. 1995
Size and number of pancreatic cysts increase with age Zhang. et al. 2002
? 80~90% pseudocyst
? 10% cystic neoplasm
(1% of primary pancreatic neoplasm)

4. Cystic lesion of pancreas
A broad spectrum of pathological entities
Distinguish pancreatic pseudocyst/ non-neoplastic cyst from pancreatic cystic neoplasm
Distinguish benign cystic neoplasm from potential malignant cystic neoplasm

5. Neoplastic lesions Non-neoplastic lesions Serous cystic neoplasm
Mucinous cystic neoplasm
Intraductal papillary mucinous neoplasm (IPMN)
Cystic endocrine neoplasm
Solid Pseudopapillary neoplasm
Ducal adenocarcinoma with cystic degeneration
Acinar cell cystadenocarcinoma
Non-neoplastic lesions
Pseudocyst
Inflammatory pancreatic cyst
Simple epithelial cyst
VHL
Cystic fibrosis

6. Epidemiology Type Gender Peak age % Serous cystadenoma F>M 70s
Brugge WR. et al.NEJM.2004.
Type
Gender
Peak age %
Serous cystadenoma
F>M
70s
32-39
Mucinous cystic neoplasm
40s
10-45
Intraductal papillary mucinous neoplasm
M=F
50s
21-33
Solid pseudopapillary neoplasm
30s
<10
Cystic endocrine neoplasm
Ductal adenocarcinoma with cystic degeneration
M>F
<1
Acinar-cell cystadenocarcinoma

7. Presentation >1/3 of Case Found incidentally during imaging
Jaundice.. Abdominal pain..
weight loss.. Anorexia..
History of pancreatitis
History of alcohol abuse
History of abdominal injury
Spinelli KS et al. Ann Surg.2004
Goh BK et al. Am J Surg.2006
Frenandez-del Castilo C et al. Arch Surg.2003
Allen PJ et al. J Gastrointest Surg.2003
>1/3 of Case
Symptomatic cysts are associated with higher risk of malignancy
?Cofounding with increased size

8. Role of CT Characterization of pancreatic cysts
May facilitate differentiation between histological variants for larger lesions
Remain non-diagnostic for small lesions
Firm diagnosis ~ %

9. Cyst with solid component
Microcystic
Cyst with solid component
Unilocular Cyst
Marcocystic
Dushyant V. Sahani et al. RadioGraphics 2005
Massachusetts General Hospital

10. Microcystic lesion: serous cystic neoplasm

11. Mucinous cystic neoplasm
Marcocystic lesion
Mucinous cystic neoplasm

12. Cyst with solid component IPMN

13. Unilocular cyst

14. Peripheral curvilinear
SCN
MCN
IPMN
Location
Even
Body/tail
Head
Septae
Yes No
Locularity
Microcystic
macrocystic
Marcocystic
Calcifications
Central stellate
Peripheral curvilinear
None
Pancreatic duct
PD displaced
PD dilated & mucin

15. Role of MRI Better delineate the architecture of cystic lesion
Better delineation of pancreatic duct
Not superior to thin cut CT in making diagnosis

17. Role of PET scan
Italian group at Padua Sperti C et al. J Gastrointest surg. 2005
> 90% sensitivity / positive predicting value distinguish malignant from benign
Unable to distinguish pre-malignant from benign

18. morphologyaccuracy ~ 51%
Role of EUS
morphologyaccuracy ~ 51%
Determine type and structure of cystic lesion
Facilitate fine needle aspiration
Examination of pancreatic ducts and parenchyma

19. Fine needle aspiraton cystic fluid analysis
Cytology
Tumor markers
CEA, CA19-9, CA 15-3, CA 72-4
Amylase
Others

21. Serous cystic neoplasm Mucinous cystic neoplasm
Viscosity
Amylase
CEA
Cytology
EUA
Serous cystic neoplasm ↓
Glycogen
microcysts
dense septations honeycomb like. central calcification.
Mucinous cystic neoplasm ↑ ↔
Mucin
multiple fluid filled cavities
thin septations larger than SCN
peri. Calcification
IPMN
Dilated pancreatic duct
Connection to duct Multilocular
No septations/ calcification
Pseudocyst
Histiocyte
Internal echoes representing debris Unilocular
Pancreatitis parenchymal change

23. Small cystic lesions ( less than 3cm)
~50% pre-malignant potential
~ 13-20% malignancy ( < 3cm)
Resect or not to resect?
Surveillance? How? How Often?
EUS/ CT
Individualized decision
Retrospective study
Selection bias
Overestimate the risk

24. End