Cystic Neoplasms of the Pancreas

1. Cystic Neoplasms of the Pancreas O.Benjaminov Rabin Medical Center Beilinson Campus benjaminovo@clalit.org.il Paris 2008

2. Becourt in 1830, "the size of a child’s head and composed of very strong fibrous walls“ Becourt PJ BG, Recherches sur le pancreas: ses functions et ses alterations organique. Strasbourg: Levrault 1830

4. 32-39% 10-45% 21-33%

5. Cystic Neoplasms of the Pancreas √ Serous cyst √Mucinous Cyst √IDPMT √Other rare cystic tumors √ Incidentalomas -- Pancreatic pseudocysts

6. Mucinous (macro) Neoplasms of the Pancreas • Most common of pancreatic cystic neoplasms • 95% women, 4th – 6th decade • 70%-90% pancreatic tail or • distal body • Usually multilocular (six or • more cysts > 2 cm). • May be unilocular. • Malignant potential • May have scattered/peripheral Ca (18%). • Malignancy correlates with multilocularity, mural nodules, • thick walls, thick septations and calcifications. Sahani, D. V. et al. Radiographics 2005;25:1471-1484

7. Mucinous (macro) Neoplasms of the Pancreas

8. Mucinous (macro) Neoplasms of the Pancreas

9. Mucinous (macro) Neoplasms of the Pancreas

10. Mucinous (macro) Neoplasms of the Pancreas

11. Serous (micro) Cystadenomas of the Pancreas Serous (micro) Cystadenomas of the Pancreas • Second most common cystic neoplasm of pancreas • Benign tumor • Women > 50 y.o • Predilection for the • pancreatic head • Multiple cysts (0.2-2.0 cm) – avg. 10 cm. • central stellate scar that can calcify (Ca=38%)

12. Serous (micro) Cystadenomas of the Pancreas

13. Serous (micro) Cystadenomas of the Pancreas

14. Serous (micro) Cystadenomas of the Pancreas

15. Serous (micro) Cystadenomas of the Pancreas

16. Serous (micro) Cystadenomas of the Pancreas

17. Serous (micro) Cystadenomas of the Pancreas Association between VHL and SCA – 15%-30%

18. Serous (micro) Cystadenomas of the Pancreas VHL – Von Hippel Lindau 1

19. Serous (micro) Cystadenomas of the Pancreas potential malignancy risk - 3% Since 1989: 673 SCA (71 series, 40 case reports –10 CA) Digestion 2003;68:24-33

20. Serous (micro) Cystadenomas of the Pancreas macrocystic serous adenoma and micro-macro (mixed) serous cystadenoma

21. Intarductal Papillary Mucinous Tumors of the pancreas (IPMT) • 1982 – Ohaishi (triad) • Mucin producing tumors • Wirsung dilatation • Protruding papilla

22. Intarductal Papillary Mucinous Tumors of the pancreas (IPMT) • M=F, 60-80 y.o • Incidental diagnosis 30%, most are • symptomatic: • Pancreatitis like pain, diabetes • Malignant potential, more curable • than pancreatic adenocarcinoma

24. 13/2/06 6/9/06

25. 1/2

26. 2/2

27. Intarductal Papillary Mucinous Tumors of the pancreas (IPMT)

30. 1/2

31. 2/2

32. Cystic Neoplasms of the Pancreas

33. Solid and papillary epithelial neoplasms (Hamoudi Tumor) Young females (95%) – 25 y.o Low malignant potential Large – avg. 9-10 cm Fibrous capsule, hemorrhage, necrosis

34. Cystic Neoplasms of the Pancreas Cystic degeneration

35. Cystic Neoplasms of the Pancreas

36. Cystic Neoplasms of the Pancreas

37. Cystic Neoplasms of the Pancreas Lymphoma

38. Incidentalomas • Incidence 0.2-0.7% (autopsy – 24%) • Natural history – data limited • More than half of them are either malignant • or pre-malignant. They are unlikely to be pseudocysts • however cysts < 2cm are unlikely to cause morbidity or mortality Arch Surg. 2003; 138: 427-434 Annals Surg 2004;239:651 AJR 2005;184:20-23 Am J Gastroenterol 2007; 102: 2339-2349

39. Algorithm for the management of incidental pancreatic cysts MGH 2003

40. Incidental Pancreatic Cyst >2.5 cm < 1 cm 1 – 2.5 cm Symptomatic & Asymptomatic Asymptomatic F/U US or CT Surgery EUS & FNA Algorithm for the management of incidental pancreatic cysts Mayo Clinics 2005

41. The American Society for Gastrointestinal Endoscopy (ASGE) Cystic lesions of the pancreas, even when found incidentally,require diagnostic evaluation regardless of size because they may represent malignant or premalignant neoplasm. March 2006 also supported by: American College of Gastroenterology – Oct . 2007

42. Cystic Neoplasms of the Pancreas Conclusions In the absence of clear evidence of previous pancreatitis cystic lesions are considered neoplastic. Imaging plays an important role in defining architecture and relation to surrounding organs as well as communication with the pancreatic ductal system. A multimodality approach should be taken. Incidental cystic lesions – management controversial for lesions asymptomatic < 2 cm a conservative approach is reasonable

43. Merci תודה Thank You

45. Epidemiology of Cystic Pancreatic Tumors Pseudocysts account for > 70% of all cystic lesions Cystic neoplasms thought to account for 20% of cystic lesions Cystic neoplasms represent only 1% of all pancreatic neoplasms. This figure may be incorrect as many asymptomatic cystic tumors do not have surgery or FNA The prevalence of the more common cystic tumors: Mucinous cystic neoplasm (MCN) 10 - 45% Intraductal Papillary Mucinous Tumor (IPMT) 21 - 33% Serous cystadenoma 32 - 40% Solid pseudopapillary tumor (SPT) < 10% Others are rare: acinar cell cancer < 1%

46. Cystic Neoplasms of the Pancreas Cystic Islet Cell Tumor

47. Cystic Neoplasms of the Pancreas Pancreatic Metastases

48. Cystic Neoplasms of the Pancreas Cystic lymphangioma

49. Simple Cyst Mucinous Cyst Serous Cyst Mucinous Cyst Pseudocyst