Pancreatic Cystic Lesions an overview Journal Club 11

Pancreatic Cystic Lesions: an overview Journal Club, 11 Dicembre 2017 Ludovica Venezia

Pancreatic Cystic Lesions ✴ Prevalence of incidental pancreatic cystic lesions in the adult population ranges from 2. 6 to 19. 6% ✴ Increase of prevalence, size and numbers with age ✴ Natural history still partially unclear: some show benign behavior, others have a malignant potential and are precursors of pancreatic ductal adenocarcinoma importance of correct management ✴ Signs/symptoms include: abdominal pain, acute pancreatitis, nausea, vomiting, weight loss, anorexia, exocrine pancreatic insufficiency and steatorrhea, recent onset or worsening diabetes, obstructive jaundice, palpable mass

Pseudocyst ✴Initial evaluation of a pancreatic cyst should be directed towards exclusion of pseudocyst ✴Most common cystic lesion of the pancreas (70 -75%) ✴A fluid collection of pancreatic juice with a well-defined capsule of fibrous or granulation tissue BUT without an epithelial lining, calcification/debris possible ✴History of acute (necrosis) or chronic (elevated pressure) pancreatitis, rarely abdominal trauma ✴At least 4 weeks after an acute injury

Pseudocyst: treatment ✴ 50% resolve spontaneously ✴ Indication for drainage: symptoms, enlargement > 6 cm, complications (infection, GI obstruction, hemorrhage), suspicion of malignancy ✴ Intervention: endoscopic or percutaneous or surgical drainage

Cystic Pancreatic Tumors

✴ All Cystic Pancreatic Tumors patients with pancreatic cystic neoplasms require a diagnostic work-up: high resolution imaging techniques, such as MRI with MRCP and EUS + FNA in doubtful case ✴ Evaluate personal and familial history for pancreatic cancer and/or other malignancies, consistent with Von Hippel–Lindau syndrome (haemangioblastoma, clear cell kidney carcinoma, NETs, pheochromocytoma) ✴ Measure ✴ No and monitor glucose and Ca 19 -9 levels additional examinations are required when the patient, after diagnosis, is found to be unfit for any treatment and asymptomatic

Serous Cystadenoma ✴ Benign (but 26 cases of cystadenocarcinoma in the literature) ✴ 75% W, grandmothers neoplasm ✴ Mainly head of the pancreas ✴ Lobulated, honeycombed microcystic appearance or polycistic, central scar (with calcification in 20%) ✴ Resection ✴ Otherwise, only if symptomatic imaging annual follow-up with MRI, glucose, Ca 19. 9 until fit for surgery

Mucinous Cystic Neoplasm Premalignant lesion 99% W, mothers neoplasm 95% body and tail of the pancreas Septated or uniloculated macrocyst FNA: CEA >192 ng/ml, low amylase Resection ALWAYS! Large size (>4 cm), mural nodules, mass forming lesions or peripheral “egg shell” calcifications suggestive of for invasive malignancy

IPMN ✴ Intraductal papillary mucinous neoplasm: degenerated cells of the pancreatic ducts producing mucus pancreatic cysts ✴ 10 -15% ✴M of pancreatic cystic neoplasm = W, 50 -70 years old (main duct earlier than branch) ✴ Mandatory: communication with pancreatic duct or branches FNA: high amylase and mucin ✴ Increased risk of ductal adenocarcinoma (main>branch) ✴ Synchronous and metachronous extrapancreatic malignant diseases in 20 -30% of patients with IPMN

IPMN: main duct Segmental or diffuse dilation of MPD > 5 mm without causes of obstruction Prevalence of cancer 60 -90%: partial or total pancreasectomy if fit for surgery IPMN mixed type is managed as IPMN main duct High risk stigmata: MPD > 10 mm, enhancing mural nodule > 5 mm, obstructive jaundice

IPMN: branch duct Pancreatic cysts > 5 mm that communicate with MPD through branch ducts Mainly head and uncinate process May be multifocal, macro or micro cystic, “bunch of grapes” Typically indolent behavior BUT 5 -40% show malignant degeneration Monitor development of high risk stigmata and worrisome features

IPMN: branch duct

Solid pseudo-papillary neoplasm 1 -2% of exocrine pancreatic tumors Young W without significant symptoms Well encapsulated heterogeneous mass with solid and cystic composition, varying amounts of necrosis and hemorrhage Mainly benign and indolent, ~15% can be malignant with MTS at diagnosis Complete resection and lifelong follow-up indicated

Cystic Neuroendocrine Tumors Uncommon, often a component of a large NET with cystic degeneration or necrosis Limited data are available for a detailed analysis and for management Less commonly associated with lymph node and liver metastases than solid NETs At imaging: thin, smooth peripheral enhancement > than pancreatic parenchyma.

Take Home Messages All cystic lesions require a diagnostic work-up with high resolution imaging (HR-CT, MRI, EUS) Investigate familiar and personal history Evaluate and monitor the presence of worrisome features or high-risk stigmata in order to establish a follow-up vs surgery No additional examinations if unfit for any treatment and asymptomatic A cystic lesion, without suspicious signs, do not exclude the patient from organ transplantation. Otherwise perform CH-EUS+FNA and discuss with surgeon.

Bibliografia • Tanaka M, Fernandez-del Castillo C, Adsay V et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012; 12: 183– 197 • Tanaka M, Fernandez-del Castillo C, Kamisawa T. Revisions of the International Consensus Fukuoka Guidelines for the Management of IPMN of the Pancreas. Pancreatology. 2017; 17(5): 738 -753. • Italian Association of Hospital Gastroenterologists and Endoscopists; Italian Association for the Study of the Pancreas. Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms. Dig Liver Dis. 2014; 46(6): 479 -93. • European Study Group on Cystic Tumours of the Pancreas. European experts consensus statement on cystic tumours of the pancreas. Dig Liver Dis. 2013; 45(9): 703 -11. • Vege S S, Ziring B, Jain R et al. American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 2015; 148: 819– 822