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Pancreatic C ystic Neoplasms

Pancreatic C ystic Neoplasms. Bible Class 4th Sept.2013. Universitätsklinik für Viszerale Chirurgie und Medizin. What type of pancreatic cysts exist ?. Why is this differentiation important ?.

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Pancreatic C ystic Neoplasms

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  1. PancreaticCysticNeoplasms Bible Class 4th Sept.2013 Universitätsklinik für Viszerale Chirurgie und Medizin

  2. What type of pancreatic cysts exist ? • Why is this differentiation important ? Post-inflammatory fluid collectionPseudo-,-PseudocystPostnecroticsequestrumParasitic, Ecchinococcal etc. AcquiredCysts: Benign • CysticNeoplasms: • IPMN: Intraductalpapillarymucinousneoplasm • MCN: Mucinouscysticneoplasm • SCN: Serouscysticadenoma/ neoplasm • SPN: Solid pseudopapillaryneoplasm • CPEN: Cysticpancreaticendocrineneoplasm CongenitalCysts: True cysts Enterogenouscysts/ duplicationcysts(Epi)dermoidcysts, Endometriose Polycysticdiseases; CysticFibrosis RiskMalignancy CysticNeoplasms:

  3. How frequent are neoplastic pancreatic cystic lesions ? Average: 2.5% Age > 70 years: 10-20%* *: MRI in non-pancreaticdisease: 20% of 1444 patients; Zhang XM et al. Radiology 2002

  4. Key features: Serous Cystic Neoplasm • Malignant potential: • Location: • Demographics, rate: • Morphology: • micro-, oligo-, macrocystictypically: multicysticcluster (each < 2 cm) = honeycumbedNocommunicationwithpancreaticduct • Stroma: (centralfibrousand) calcified (stellatescar) • NO • throughoutthepancreas • (older) women (80%), 15-20% of PCNs

  5. Key features: IPMN • Types: • Malignant potential: • Location: • Demographics, rate: • Morphology: • Main-, branch-duct, mixed type • Cysticdilatationmain(> 6 mm) orsidebranches; M: Fish-mouth, globulesofmucin(= masses) • Stroma: Lack ofovarianstroma (vs. MCN) • Yes (esp. main/combinedduct IPMN) • M: head BD: multifocal !! • Equal m/w, middle-age/old; >25% of PCNs

  6. Key features: MCN • Yes (but lowerthan IPMN) • Malignant potential: • Location: • Demographics, rate: • Morphology: • thick-walledsinglecyst, oftenseptations • Epitheliallayerwithmucin-producingcells, ovarian-likestroma • Nocommunicationwithpancreaticduct • Body/tail (95%), alwayssinglelesion! • Middle-agedwomen (95%), 25% of PCNs

  7. Riskofmalignancy in pancreaticneoplasticcysts ? Whatfactorsdeterminemalignantrisk in IPMN/MCN? • IPMN: BD-: • MD-: • MCN: • SCN: • SPN: • CPEN: ++ ̴40% (6-46%) RiskofHGD/ malignancy1 ++++ ̴ 65% (57-92%)RiskofHGD/ malignancyin 5 y 1 ++ 6-36% Prevalencemalignancy1 (+)VERY low(malignant= serouscystadenocarcinoma) + Low malignant potential 2 Variable 2 • Size • Histopathological type 1: Sakorafas GH et al. SurgOncol. 2011; 2 Sakorafas GH et al. SurgOncol 2012

  8. What are high-risk stigmata for malignancy in IPMN/MCN? • Obstructivejaundice (andcysticlesionofthepa-head) • Enhancing solid componentwithincyst • Main pancreaticduct> 10 mm in size Consequence? Considersurgery, ifclinicallyappropriate

  9. If no high-risk stigmata in IPMN/MCN: What are worrisome features ? Clinical: Pancreatitis Imaging: Cyst > 3 cm Thickened/enhancingcystwalls Main ductsize 5-9 mm Non-enhancingmuralnodule Abrupt change in caliberofpancreaticduct with distal pancreaticatrophy Consequence? Endo-Sonography

  10. What are the advantages of EUS in diagnostic workup of pancreatic cysts ? • Superior, higher-resolution imagingofthepancreas(ductalcommunication, additional (smaller) cysts, nodules etc.) • Fine-needle-aspiration (FNA): sampling fluid forCytologyandtumormarkers

  11. What are drawbacks of EUS ? • Operator-Dependent Investigation • Sampling Error • Contamination (gastric wall) • Low cellularity -> Low senstivitye.g. SCN only 30-40% enoughcellsdiagnosticaccuracy: 10-60%often NON-diagnostic Including high-grade atypicalepithelialcells: diagnostic in mucinouscysts diagnosticaccuracy: 80%

  12. What are EUS features leading to consider surgery ? • Definemuralnodule(s): 3-9 foldriskmalignancy • Main ductfeaturessuspiciousforinvolvement • Cytology: suspiciousor positive formalignancy

  13. EUS-FNA: Fluid Analysis in Cysts

  14. CEA in Cyst-Fluid: What for ? Useful ? • Mucinous vs. Non-mucinous (serous) • Cut-off unclear: e.g. > 800 ng/mL • Nocorrelationwithriskofmalignancy

  15. How to perform surveillance for BD-IPMN and MCN? < 1 cm: 1-2 cm: 2-3 cm: > 3 cm: CT/MRI in 2-3 years CT/MRI yearly (for 2 years)lengthenintervalifnochange EUS in 3-6 months Lengtheninterval, alternating EUS and MRI Considersurgery in young, fit patients (longsurveillance) Close surveillance alternating MRI with EUS every 3-6 months Stronglyconsidersurgery (in young, fit patients)

  16. Which syndrome associates with multiple/oligocystic SCN ? Hippel-Lindau-Syndrome

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