![Cyst Fluid Analysis
Viscosity Amylase Cytology
Pseudocyst Low High Inflamm.
SCA Low Low 5% +
MCA High Low 40% +
MCAC High Low 67% +
CEA CA 15-3 CA 72-4
Pseudocyst Low Low Low
SCA Low Low Low
MCA High High Low
MCAC High High High
[1] Lewandrowski KB, et al. Ann Surg 1993, 217:41-7.
[2] Brugge WR, et al. N Engl J Med 2004, 351:1218-26.](https://image.slidesharecdn.com/ketul-clp-130311041848-phpapp01/85/Cystic-lesions-of-the-pancreas-42-320.jpg)
Cystic lesions of the pancreas
- 1. Dr. Ketul V. Shah 1st year MCh G.I.Surgery resident V.S. Hospital, Ahmedabad Discussion; Dr Sanjay Nagral, Consultant GI surgeon,Mumbai.
- 2. Cystic lesion in Pancreas Task ahead I. Is the lesion from pancreas? II. Lesion is solid or cystic? III. Neoplastic v/s non-neoplastic? IV. SCA v/s MCN v/s IPMN? V. Management?
- 3. CASE HISTORY 45y/F c/o recurrent vomiting and loss of appetite - 6 mths. Vomitus contained food and occurred ½ to 1 hour after meals & was non-bilious, non-projectile h/o diffuse abdominal pain significant weight loss ++ Anorexia ++
- 4. There was no preceding history of any severe abdominal pain or jaundice No h/o lump in abdomen, abdominal distension Pt is not a k/c/o diabetes and no other positive medical or surgical history
- 5. ON EXAMINATION pallor +, No LNpathy P/A- soft, non tender, no palpable lump, no organomegaly. No ascitis. other systems normal.
- 6. INVESTIGATIONS DONE LFT – wnl S. Amylase and Lipase were normal USG - A cystic lesion in the pancreatic head and neck region of about 7x5cm CECT - 73x60 mm cystic lesion in pancreatic head & neck region; cystic wall-3mm; MPD- normal; no peri-pancreatic LN or fluid. S. CA 19-9 – wnl S. CEA - wnl
- 8. While approaching a cystic lesions we need to know…. Broad differential diagnosis Epidemiology of common lesions Clinical presentation Blood tests Imaging Histology
- 9. Broad D/D’s of Cystic Pancreatic Lesions 1) Pseudocyst (75-80%) 2) Common cystic pancreatic neoplasms Mucinous cystic neoplasm (10-45%) Serous cystic neoplasm (32-39%) IPMN (21-33%) 3) Rare cystic pancreatic neoplasms Solid pseudopapillary tumor (<10%) Acinar cell cystadenocarcinoma (<!%) Lymphangioma Hemangioma Paraganglioma
- 10. 4) Solid pancreatic lesions with cystic degeneration Pancreatic adenocarcinoma (<1%) Cystic islet cell tumor (insulinoma, glucagonoma, gastrinoma) (<10%) Metastasis Cystic teratoma Sarcoma 5) Hydatid cyst 6) Lymphatic cyst 7) True epithelial cysts a/w- von Hippel–Lindau disease autosomal -dominant polycystic kidney disease
- 11. Imaging in Cystic lesions…. As against Solid lesions, Imaging may be diagnostic in many cystic lesions, obviating further investigations
- 12. Imaging in cystic lesions of pancreas; How does it help???
- 13. Four Morphologic Types of Cystic Lesions of the Pancreas
- 14. a) Unilocular Cyst Pseudocyst- most common Other causes- IPMN occasionally Unilocular serous cystadenoma Lymphoepithelial cyst Multiple von Hippel-Lindau Pseudocysts
- 15. b) Microcystic Lesions Serous cystadenoma (Only lesion included in this category)
- 16. c) Macrocystic Lesions Mucinous cystic neoplasms Intraductal Papillary Mucinous Neoplasm (IPMN)
- 17. d) Cysts with a solid component - Unilocular or multilocular True cystic tumors or solid pancreatic neoplasms with cystic component/degeneration Solid pseudopapillary tumor (SPEN) Mucinous cystic neoplasms IPMNs Islet cell tumor Adenocarcinoma Metastasis
- 18. Let us look at the possibilities in our patient……
- 19. Could this patient have PANCREATIC PSEUDOCYST? Symptoms Abdominal pain (80 – 90%) Lump in abdomen Nausea / vomiting ( due to gastric or duodenal compression) Early satiety Bloating, indigestion Jaundice ( due to compression of bile duct) Hemorrhage Signs Tenderness Abdominal fullness Palpable mass
- 20. Blood tests in suspected pseudocyst Amylase/Lipase
- 21. Imaging in Pseudocyst….. Ultrasonography Most practical & Sensitivity 75 – 90% limited by patient habitus, operator experience and air in stomach CT scan Gold standard for initial assessment and follow-up Sensitivity 90- 100% MRI Better detail of content of cyst MRCP Establish the relationship of the pseudocyst to the pancreatic ducts Endoscopic Ultrasonography (EUS +/- FNA) Distinguishing pancreatic cystic lesions, helps in FNA
- 22. So, if you have a cystic lesions with….. Sudden onset of pain consistent with pancreatitis pain Imaging features of associated pancreatitis Unilocular cyst; and Elevated amylase/lipase You may not investigate any further…… It must be a pseudocyst
- 23. Common neoplastic lesions and their features….
- 24. Cystic neoplasm of pancreas
- 25. MUCINOUS CYSTIC NEOPLASMS Most common - 10% to 45% (MCA -67%, MCAC - 33%) > 95% in women ( Mean ~ 50 yrs) Typically involve the body and tail of the pancreas Never multifocal, occurring only in one location within the pancreas.
- 26. Asymptomatic in 75% cases If symptoms, usually due to mass effect Adominal pain Palpable mass
- 27. CT or MRI of the abdomen Complex macrocystic mass with internal septations MRCP no communication between duct and the cyst Contrast enhanced scans show enhancement of the cyst wall and accentuate any septations and mural nodules Distal to the tumor, the pancreas may show changes of CP Presence of mural nodule and septal calcification s/o – malignancy
- 28. EUS can identify septations and cyst wall nodules in more detail than MRI or CT Allows cyst wall biopsy and cyst fluid aspiration for analysis Cyst fluid analysis generally reveals thick and mucoid material and low fluid amylase elevated tumor markers (CEA) mucinous epithelial cells by cytology
- 29. Mucinous Cystadenocarcinoma Complex macrocystic lesion with internal septations Peripheral and septal calcification indicative of malignancy (arrowheads)
- 30. SEROUS CYSTADENOMAS Second MC Cystic tumor of the pancreas formerly known as microcystic adenomas Occurring mostly in women (75%) with a mean 62 years Most (50% to 70%) occur in the body or tail of the pancreas An association with von Hippel-Lindau disease
- 31. Mostly asymptomatic being detected during evaluation for other unrelated conditions Can present with a palpable mass - size (10 to 25 cm)
- 32. Serous Cystadenoma Lesion with numerous microcysts giving a “honey-comb” appearance Lobulated outline Central stellate scar
- 33. Serous cystadenoma Pathognomonic image by CT scan is that of a spongy mass with a central “sunburst” calcification - only 10% of patients Visualization of four of the following five CT and MRI features aid in making the diagnosis location in the pancreatic body and tail wall thickness < 2 mm lobulated contour lack of communication with the pancreatic duct minimal wall enhancement
- 34. IPMN (Intra-ductal Papillary Mucinous Neoplasm) Types - depend on involvement of duct main pancreatic duct, isolated side branches, or a combination of both Benign (adenoma), borderline, or malignant Malignant neoplasms account for 60% of IPMNs
- 35. IPMN FEATURES Equal frequency in men and women Median age at diagnosis - about 65 years 75% of patients are symptomatic Abdominal pain and weight loss – MC complaints Recurrent pancreatitis or Acute pancreatitis Patients with malignant neoplasms are more likely to be older and more likely to present with jaundice or new-onset diabetes
- 36. DIAGNOSIS Differentiation of IPMN from other cystic pancreatic masses may be difficult at CT Most reliable findings for the diagnosis Presence of a communication between the cystic lesion and the main pancreatic duct Presence of mural nodules projecting into the main pancreatic duct or cystic lesions
- 37. DIAGNOSIS Diffusely distended pancreatic duct with mucinous filling defects and grape-like, cystic, space-occupying lesions Sensitivity in diagnosing an IPMN highest for MRI with MRCP (88%),followed by ERCP (68%) and CT (42%)
- 38. Pathognomonic for IPMN in ERCP A wide and gaping papilla with secretion of mucin and filling defects in the dilated pancreatic duct –FISH MOUTH AMPULLA
- 39. Cystic lesions of pancreas; will blood tests help ? Amylase and/or Lipase?? CEA? Ca 19-9 ?? Not diagnostic of any of the cystic pancreatic tumors Only provide corroborative evidence
- 40. Serum amylase or lipase levels Increased - pseudocyst, IPMN Serum CA 19-9 & CEA normal - benign cystic pancreatic tumors modestly elevated - MCNs and IPMNs, particularly patients with malignancies Markedly elevated -retention cyst secondary to obstruction of the main pancreatic duct by an adenocarcinoma.
- 41. Cystic lesions of Pancreas; will aspiration and analysis of fluid help?
- 42. Cyst Fluid Analysis Viscosity Amylase Cytology Pseudocyst Low High Inflamm. SCA Low Low 5% + MCA High Low 40% + MCAC High Low 67% + CEA CA 15-3 CA 72-4 Pseudocyst Low Low Low SCA Low Low Low MCA High High Low MCAC High High High [1] Lewandrowski KB, et al. Ann Surg 1993, 217:41-7. [2] Brugge WR, et al. N Engl J Med 2004, 351:1218-26.
- 43. Coming back to our case…
- 44. Our patient has…. No clear cut diagnosis on history Serum markers were non-informative Imaging not diagnostic Therefore EUS guided FNA was done..……Adenocarcinoma with cystic degeneration
- 45. DR. KETUL SHAH