5/17/2013 Pancreas Cysts Overview Common Work-up often - - PowerPoint PPT Presentation

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5/17/2013 Pancreas Cysts Overview Common Work-up often - - PowerPoint PPT Presentation

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5/17/2013 Pancreas Cysts Overview Common Work-up often nondiagnostic Postgraduate Course in General Surgery Possibly benign, premalignant, malignant Pancreas cancer difficult to cure Pancreas Cysts Real consequences of

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5/17/2013 1

Postgraduate Course in General Surgery

Pancreas Cysts

Eric K. Nakakura San Francisco, CA

May 17, 2013

Pancreas Cysts

  • Common
  • Work-up often nondiagnostic
  • Possibly benign, premalignant, malignant
  • Pancreas cancer difficult to cure
  • Real consequences of under-/over-treatment

Overview

Pancreas Cysts

  • 2.6% (73/2832) overall
  • 8.7% in 80 - 89 year-olds
  • Size: 2 - 38 mm (mean, 8.9 mm)
  • More common in Asians (odds ratio = 3.57)

Prevalence of unsuspected cysts

Laffan et al. AJR 2008

Pancreas Cysts

  • Benign

– Pseudocyst – Serous cystic neoplasm (SCN) – Simple cyst, retention cyst, congential, lymphoepithelial cyst

  • Potentially malignant

– Solid pseudopapillary neoplasm (SPN) – Intraductal papillary mucinous neoplasm (IPMN) – Mucinous cystic neoplasm (MCN) – Neuroendocrine tumor

  • Malignant

– Ductal adenocarcinoma

Differential diagnosis

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5/17/2013 2 Pancreas Cysts

Suboptimal preoperative diagnosis

Correa-Gallego et al. Pancreatology 2010

  • 1/3 had incorrect preoperative diagnosis
  • 5% not neoplastic

Pancreas Cysts

  • Intraductal papillary 75 (35%)

mucinous neoplasm (IPMN)

  • Mucinous cystic

43 (19%) neoplasm (MCN)

  • Serous cystadenoma

23 (11%)

  • Pseudocyst

29 (14%)

  • Ductal adenocarcinoma 14 (7%)
  • Other 28 (13%)

Pathological diagnosis (n = 212)

Fernandez-del Castillo et al. Arch Surg 2003

Pancreas Cysts

  • Pancreatic epithelial neoplasia
  • Intraductal papillary mucinous neoplasia
  • Mucinous cystic neoplasms

Precursors to pancreas cancer

Pancreas Cysts

  • Pancreatic epithelial neoplasia
  • Intraductal papillary mucinous neoplasia
  • Mucinous cystic neoplasms

Precursors to pancreas cancer

Cystic Too small to see

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5/17/2013 3 Pancreas Cysts

  • Pancreatic epithelial neoplasia
  • Intraductal papillary mucinous neoplasia
  • Mucinous cystic neoplasms
  • Asymptomatic pancreas cyst might be a treatable

precursor to pancreas cancer

Precursors to pancreas cancer

Cystic Too small to see

Pancreas Cysts

  • Ignore it?
  • Follow it?
  • Resect it?

What should be done if a pancreas cyst is seen?

Pancreas Cysts

  • Size
  • Imaging characteristics
  • Clinical factors
  • Endoscopic ultrasound (EUS)/

Fine needle aspiration (FNA)

Factors to consider

Pancreas Cysts

  • Serous cystic neoplasm (SCN)
  • Solid pseudopapillary neoplasm (SPN)
  • Mucinous cystic neoplasm (MCN)
  • Intraductal papillary mucinous neoplasm (IPMN)

Neoplastic cysts

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5/17/2013 4 Pancreas Cysts

  • Nonmucinous
  • Serous cystic neoplasm (SCN)
  • Solid pseudopapillary neoplasm (SPN)
  • Mucinous
  • Mucinous cystic neoplasm (MCN)
  • Intraductal papillary mucinous neoplasm (IPMN)

Neoplastic cysts

Pancreas Cysts

Dixon et al. WJGS 2013

Pancreas Cysts

Jani et al. Diagn Ther Endosc 2011

Pancreas Cysts

IPMN: Main- more aggressive than branch-duct

Tanaka et al. Pancreatology 2006

  • Main duct
  • Branch duct
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5/17/2013 5 Pancreas Cysts

Management of IPMNs

Tanaka et al. Pancreatology 2006

  • Main duct

– Most patients should undergo resection

  • Branch duct

– Sendai (Tanaka) Criteria for resection

  • Size > 3 cm

moderate

  • Symptoms

strong

  • Mural nodule

strong

Pancreas Cysts

Natural history of branch duct IPMN

Maguchi et al. Pancreatology 2012

Pancreas Cysts

Case 1:

  • 74-year-old man

– Weight loss (30 pounds) over 5 months and 3-4 loose, floating stools/day

Pancreas Cysts

Case 1:

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5/17/2013 6 Pancreas Cysts

Case 1:

  • What is the diagnosis and treatment?

Pancreas Cysts

Main duct IPMN

SMA SMV

Pancreas Cysts

Main duct IPMN

Pancreas Cysts

Main duct IPMN

  • Pathology

– Mixed main duct/branched duct IPMN (8.5 cm) with an invasive colloid carcinoma (< 0.5 cm) – Margins negative – pT1N0 (0/52 LNs)

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5/17/2013 7 Pancreas Cysts

Case 2:

  • 58-year-old woman

– Early satiety, weight loss, loose stools, new

  • nset diabetes

Pancreas Cysts

Case 2:

Pancreas Cysts

Case 2:

  • What is the diagnosis and treatment?

Pancreas Cysts

Serous cystic neoplasm

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5/17/2013 8 Pancreas Cysts

Case 3:

  • 20-year-old woman

– Intermittent epigastric pain over 4 years

Pancreas Cysts

Case 3:

Pancreas Cysts

Case 3:

  • What is the diagnosis and treatment?

Pancreas Cysts

Solid pseudopapillary neoplasm

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5/17/2013 9 Pancreas Cysts

Treatment algorithm

Jani et al. Diagn Ther Endosc 2011

Pancreas Cysts

  • Common: You will see it!
  • Work-up often nondiagnostic
  • Possibly benign, premalignant, malignant
  • Pancreas cancer difficult to cure
  • Real consequences of under-/over-treatment
  • Complex decisions: work-up and management

Conclusions

Pancreas Cysts

  • Consider resection for:

– SCN: > 4cm, symptomatic – SPN: 10-15% risk of metastases – Any MCN – Any main duct IPMN – Branch duct IPMN: > 3cm, symptomatic, nodule

Conclusions

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