Cystic Neoplasms of the Pancreas O Benjaminov Rabin

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

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

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

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

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

Mucinous (macro) Neoplasms 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%)

Serous (micro) Cystadenomas of the Pancreas

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

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

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

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

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

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

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Intarductal Papillary Mucinous Tumors of the pancreas (IPMT)

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Cystic Neoplasms of the Pancreas

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

Cystic Neoplasms of the Pancreas Cystic degeneration

Cystic Neoplasms of the Pancreas

Cystic Neoplasms of the Pancreas Lymphoma

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 < 2 cm 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

Algorithm for the management of incidental pancreatic cysts MGH 2003

Algorithm for the management of incidental pancreatic cysts Incidental Pancreatic Cyst < 1 cm >2. 5 cm 1 – 2. 5 cm Symptomatic & Asymptomatic F/U US or CT EUS & FNA Surgery Mayo Clinics 2005

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

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

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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%