| What are the types of pancreatic cysts present? | Neoplasms (tumors) or benign (pseudocysts, not a cyst rather an inflammatory collection only) |
| What are the main neoplasms present (pancreatic cysts)? | Cyst adenomas (serous and mucinous)
Intraductal Papillary Mucinous Neoplasm (IPMN)
Solid Pseudopapillary Neoplasm (SPN) |
| How is the epidemiology of pancreatic neoplasm cysts? | MCNs, SCNs and IPMN are more than 80% of pancreatic cysts, first exclude pseudocysts (hx of acute or chronic pancreatitis, abdominal trauma, lack of septa loculations, solid component and cyst wall calcification on CT or MRI with high levels of amylase unlike cystic tumors)
Cystic neoplasms are slow growing, malignancy potential in MCN, IPMN and SPT
Dx: CT or MRI with contrast, ERCP for IPMN, EUS and FNA for neoplasms |
| What is MCN? | Mucinous cystic neoplasm, Cystic tumors of pancreas, less common than IPMN and SCNs.
Most are thick-walled cysts with septations filled with mucus.
Clinical spectrum may be benign to malignant, so they require histologic presence of ovarian type stroma within the tumor to get a dx of MCN
72% benign adenomas, 10% borderline, 5% carcinoma, 12% invasive cancers.
Female predominant (20:1), confined to body and tail of pancreas, age of presentation is 50
MRCP shows no connection between pancreatic duct and the cyst
EUS identifies septa, and allows cyst wall biopsy/aspiration (thick mucoid material, low amylase, elevate CEA, mucinous epithelia on histology) differentiate it from SCN (low CEA) and IPMN (high amylase) |
| What are the measures taken in response to MCN? | Since it has potential of malignancy, surgical resection is done to all of them, distal pancreatectomy w/ or w/out splenectomy is procedure of choice.
5 year survival rate is excellent for benign and borderline MCN (100% cure), and no need for long-term surviellence of pt since they are never multifocal (after resection of non-invasive MCN), while invasive MCN 5-year survival is 30-63% |
| What are SCNs? | Similar clinical presentation as MCN, mostly in body or tail of pancreas in women with age 62 years.
associated with von Hippel-Lindau disease, most pt present with vague abdominal pain, palpable mass (tumor size 10-25 cm), majority are asymptomatic
Well circumscribed pancreatic neoplasm, shows numerous tiny cysts with fibrous septa (honeycomb shape)
Filled with clear watery fluid arranged as stellate scar (may be calcified)
Spongy mass w/central sunburst calcification (pathogneumonic)
EUS shows honeycombing (more than CT), Low viscosity, low CEA, - cytology
All are asymptomatic, survielence by imaging, not pre neoplasm (not cancerous) and doesn't need resection unless new onset of symptoms. |
| What are IPMNs (intraductal papillary mucinous neoplasms)? | Papillary neoplasms in pancreatic duct with mucin hypersecretion lead to duct dilation and chronic obstructive pancreatitis.
Preneoplasmic lesions, histology shows hyperplasia to carcinoma regions w/in a single tumor.
3 groups, benign, bordeline, and malignant (invasive or non-invasive based on extension beyond basement membrane) |
| How is prevalence of IPMN? | 64% malignant neoplasm in main duct, 18% branch duct IPMN.
Equal in men and women, age of dx 65 years old
75% symptomatic w/ abdominal pain, weight loss...
Recurrent pancreatitis in 20% of pt, acute pancreatitis as first presentation in 25% of pt |
| What are image findings of IPMN? | CT (Dilation of pancreatic duct, w/ or w/out associated mass, may mimic MCN)
MRI (mural nodules, wall enhancement, mor frequent in malignant IPMN)
ERCP (patulous ampulla of vater w/ extruding mucus (pathogneumonic), pancreatography shows main duct dilation, filling defects (by mucus or tumor nodules), communication between cystic area and main duct) |
| How is the management of IPMN? | Pancreaticoduodenectomy is tx of choice for most pt (if IPMN in head)
Distal pancreatectomy (body/tail lesions)
If entire duct involved we perform total pancreatectomy.
Prognosis after resection is excellent (5 year survival is 75%, worse outcome may occur after invasive histology including lymph node metastasis, lymphovascular invasion, perineural invasion...)
So we need post op imaging for pt even without invasive tumors.
Pt w/recurrent disease localized in pancreas benifit from complete pacreatectomy |
| What is SPT (Solid pseudopapillary tumor)? | Women more affected (10:1), age in 30s, most common presentation is abdominal pain (70-80%), seconds most common finding is abdominal mass
Most are found in body and tail, large at presentation (10cm), small tumors are solid, whereas large ones show cystic degeneration (may be mixed solid and hemorrhagic pseudocystic areas).
Most are benign (but uncertain malignant potential), complete resection is tx of choice, 100% 5-year survival after R0 resection |
