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Case Capsule

Case Capsule. Dr V Gandhi. Case 1. 27 yrs housewife Occasional dull abdominal pain No other gastrointestinal symptoms Lab – normal CA 19-9 – 5 U/ml USG abdomen – cystic lesion in the head of pancreas. CT Abdomen. CT Abdomen. Whipples procedure.

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Case Capsule

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  1. Case Capsule Dr V Gandhi

  2. Case 1 • 27 yrs housewife • Occasional dull abdominal pain • No other gastrointestinal symptoms • Lab – normal • CA 19-9 – 5 U/ml • USG abdomen – cystic lesion in the head of pancreas

  3. CT Abdomen

  4. CT Abdomen

  5. Whipples procedure • Large solid cystic lesion in the head pancreas • Lesion displacing the SMV portal axis on the left side and the vessels splaying on the lesion • No significant lymphadenopathy • No liver lesions • No ascitis Post op Colonic fistula – managed conservatively

  6. Histopathology • Acinar cell carcinoma of pancreas • Margins negative • No lymph nodes involved

  7. Case 2 • 63 yrs hypertensive male • Early satiety since 2 months • One episode of acute abdominal pain • Weight loss – 3 kg • Lab – normal, CA 19-9 – 479.88 U/ml • USG abdomen – lesion in the tail pancreas

  8. CT Abdomen

  9. CT Abdomen

  10. Plan • Distal pancreatectomy + Splenectomy

  11. Case 3 • 26 yrs housewife • Dull abdominal pain in the past • No other GI symptoms • Evaluated outside – USG abdomen – cyst in the tail of pancreas – pseudocyst of pancreas

  12. CT abdomen Complex cystic lesion in body /tail pancreas Septations in the lesion

  13. EUS Cyst fluid CEA - high

  14. Surgery • Distal Pancreatectomy + Splenectomy + Segmental colectomy • HPR – Mucinous cystadenoma

  15. Cystic lesion Pancreas - Classification

  16. CYST ASPIRATION IN IMAGING UNCHARACTERIZED CYSTIC TUMOURS ENDOSCOPIC USG Currently test of choice • High resolution imaging • Highest success in obtaining cyst fluid • Safe-Fever0.6%/Pancreatitis 1.5%/Bleeding 1.5% C/I ENDOSCOPIC USG • Incidental <1 cm lesion no enhancing component • Cysts in setting of pancreatitis • Definitive diagnosis will not change Mx • Not a surgical candidate

  17. CYST FLUID ASPIRATE ANALYSIS

  18. Serous cystic neoplasms The data from multiple large single institution studies, confirm the “ benign nature of serous cystadenomas” CONSERVATIVE • Asymptomatic patient • Clear diagnosis • No solid component Followed by CT or MRI at regular intervals RESECTION • Symptomatic patient • Healthy patient with significant growth observed • Size > 4cms Tseng JF, Warshaw AL, Sahani DV, Lauwers GY, Rattner DW,Fernandez-del Castillo C Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg 2005;242:413–9; discussion 419–21

  19. mucinousneoplasms Mucinous cystic neoplasms Have a high potential of malignancy . Should undergo resection regardless of cyst size after diagnosis , ? Balance risk with mortality of surgery if <3 cms Intraductal papillary mucinousneoplasms High potential of malignancy but IPMN involving the main duct have a higher riskof malignancy than the branch duct (64% vs. 19%) IPMN- M, IPMN >3 cms should be resected IPMN -Br < 3 cm can be observed, if no enlargement of cyst size, symptoms or solid component .  Serikawa M, Sasaki T, Fujimoto Y, Kuwahara K, Chayama K. Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification. J Clin Gastroenterol 2006;40:856–62.

  20. Pancreatic incidentaloma“cystic lesions” Berland LL, Silverman SG, Gore RM, et al.Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 2010;7(10):754–73.

  21. what is frequency of follow up? Assuming lesion meets strictly applied criteria for follow-up <3 cm, no mural nodules, no main pancreatic duct dilatation, asymptomatic follow-up The Sendai guidelines <1 cm follow 1 yearly, 1 - 2 cm follow 6-monthly for 1 year then yearly for second year, 2- 3 follow every 3 to 6 months, and >3 cm be resected. American College of Radiology (ACR) guidelines Single follow-up in 1 year if < 2 cm; Follow-up every 6 months for 2 years and then yearly if 2 to 3 cm; and Lesions > 3 cm, resect unless serous cystadenoma or proven pseudocyst All of these guidelines suggest that patients must remain asymptomatic during the follow-up period

  22. what is optimal method of follow up? The ACR subcommittee recommends MRI as the preferred follow up procedure • Superior contrast resolution making the detection of septa, nodules, and main pancreatic duct communication easiest to recognize • Lack of ionizing radiation Cost and resource availability must be factored in decision. For patients older than 60 years, radiation issues may not be as compelling. Regardless of follow up procedure, careful and consistent measurements to be made Note slice number and series in the report and electronic calipersplaced on the exact image used to determine the diameters to determine whether the reported growth of a small lesion is true growth or measurement error may be difficult. . Currently, no consensus has defined growth.

  23. Pearls & Pitfalls • Heterogeneous group with many shared clinical features • Although uncommon are important because of high cure rate and potential confusion with far more common pseudocysts • 10 % all cysts in pancreas and 1 % of all tumors of pancreas • Operative differentiation may not be possible and careful pathologic evaluation of entire lesion may be necessary to arrive at a diagnosis • Majority of these tumors are treated by surgical resection

  24. Pearls & Pitfalls • The presence of a cystic pancreatic mass in the absence of a history of pancreatitis must be investigated thoroughly. • Imaging studies are very useful in delineating the cyst • Cytologic and chemical analysis of cyst fluid obtained by F N A C may provide diagnostic information. • All unexplained pseudocysts should be viewed with suspicion • The only adequate treatment of cystic pancreatic neoplasm is resection. • There is no role for internal or external drainage. • Prognosis is favorable after resection

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