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Pancreatic Cystic Neoplasms Bible Class 4th Sept.2013 Universitätsklinik für Viszerale Chirurgie und Medizin.

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Presentation on theme: "Pancreatic Cystic Neoplasms Bible Class 4th Sept.2013 Universitätsklinik für Viszerale Chirurgie und Medizin."— Presentation transcript:

1 Pancreatic Cystic Neoplasms Bible Class 4th Sept.2013 Universitätsklinik für Viszerale Chirurgie und Medizin

2 Universitätsklinik für Viszerale Chirurgie und Medizin / What type of pancreatic cysts exist ? Acquired Cysts: Congenital Cysts: Cystic Neoplasms: Post-inflammatory fluid collection Pseudo-,-Pseudocyst Postnecrotic sequestrum Parasitic, Ecchinococcal etc. True cysts Enterogenous cysts/ duplication cysts (Epi)dermoid cysts, Endometriose Polycystic diseases; Cystic Fibrosis Cystic Neoplasms: -IPMN:Intraductal papillary mucinous neoplasm -MCN:Mucinous cystic neoplasm -SCN:Serous cystic adenoma/ neoplasm -SPN: Solid pseudopapillary neoplasm -CPEN:Cystic pancreatic endocrine neoplasm Why is this differentiation important ? Risk Malignancy Benign

3 Universitätsklinik für Viszerale Chirurgie und Medizin / How frequent are neoplastic pancreatic cystic lesions ? Average: 2.5% Age > 70 years: %* * : MRI in non-pancreatic disease: 20% of 1444 patients; Zhang XM et al. Radiology 2002

4 Universitätsklinik für Viszerale Chirurgie und Medizin / Key features: Serous Cystic Neoplasm Malignant potential: Location: Demographics, rate: Morphology: micro-, oligo-, macrocystic typically: multicystic cluster (each < 2 cm) = honeycumbed No communication with pancreatic duct Stroma: (central fibrous and) calcified (stellate scar) NO throughout the pancreas (older) women (80%), 15-20% of PCNs

5 Universitätsklinik für Viszerale Chirurgie und Medizin / Key features: IPMN Types: Malignant potential: Location: Demographics, rate: Morphology: Yes (esp. main/combined duct IPMN) M: headBD: multifocal !! Equal m/w, middle-age/old; >25% of PCNs Main-, branch-duct, mixed type Cystic dilatation main (> 6 mm) or side branches; M: Fish-mouth, globules of mucin (= masses) Stroma: Lack of ovarian stroma (vs. MCN)

6 Universitätsklinik für Viszerale Chirurgie und Medizin / Key features: MCN Malignant potential: Location: Demographics, rate: Morphology: Yes (but lower than IPMN) Body/tail (95%), always single lesion! Middle-aged women (95%), 25% of PCNs thick-walled single cyst, often septations Epithelial layer with mucin-producing cells, ovarian-like stroma No communication with pancreatic duct

7 Universitätsklinik für Viszerale Chirurgie und Medizin / Risk of malignancy in pancreatic neoplastic cysts ? IPMN:BD-: MD-: MCN: SCN: SPN: CPEN: 1: Sakorafas GH et al. Surg Oncol. 2011; 2 Sakorafas GH et al. Surg Oncol ̴ 40% (6-46%) Risk of HGD/ malignancy %) ++++ ̴ 65% (57-92%) Risk of HGD/ malignancy in 5 y % Prevalence malignancy 1 (+)VERY low (+)VERY low (malignant = serous cystadenocarcinoma) +Low malignant potential 2 Variable 2 What factors determine malignant risk in IPMN/MCN? Size Histopathological type

8 Universitätsklinik für Viszerale Chirurgie und Medizin / What are high-risk stigmata for malignancy in IPMN/MCN? Obstructive jaundice (and cystic lesion of the pa-head) Enhancing solid component within cyst Main pancreatic duct > 10 mm in size Consequence? Consider surgery, if clinically appropriate

9 Universitätsklinik für Viszerale Chirurgie und Medizin / If no high-risk stigmata in IPMN/MCN: What are worrisome features ? Clinical: Pancreatitis Imaging: Cyst > 3 cm Thickened/enhancing cyst walls Main duct size 5-9 mm Non-enhancing mural nodule Abrupt change in caliber of pancreatic duct with distal pancreatic atrophy Consequence? Endo-Sonography

10 Universitätsklinik für Viszerale Chirurgie und Medizin / What are the advantages of EUS in diagnostic workup of pancreatic cysts ? Superior, higher-resolution imaging of the pancreas (ductal communication, additional (smaller) cysts, nodules etc.) Fine-needle-aspiration (FNA): sampling fluid for Cytology and tumor markers

11 Universitätsklinik für Viszerale Chirurgie und Medizin /

12 Operator-Dependent Investigation Sampling Error Contamination (gastric wall) often NON-diagnostic Low cellularity -> Low senstivity e.g. SCN only 30-40% enough cells diagnostic accuracy: 10-60% often NON-diagnostic What are drawbacks of EUS ? Including high-grade atypical epithelial cells: diagnostic in mucinous cysts diagnostic accuracy: 80%

13 Universitätsklinik für Viszerale Chirurgie und Medizin / What are EUS features leading to consider surgery ? Define mural nodule(s): 3-9 fold risk malignancy Main duct features suspicious for involvement Cytology: suspicious or positive for malignancy

14 Universitätsklinik für Viszerale Chirurgie und Medizin / EUS-FNA: Fluid Analysis in Cysts TypSCNMCNIPMNSPNPseudocyst Viscosity Mucin Amylase Cytology negative or Glyogen-con- taining cuboid cells mucin- containing column cells papillary clusters of mucin - column cells, atypia Branching papillae cuboid or cylindric cells, high cellularity, myxoid stroma «dirty material» Macrophages, Inflammatory cell ViscosityLowHigh NALow MucinLowHigh NALow Amylase< 250 U/L < 250 U/L a LowHigh

15 Universitätsklinik für Viszerale Chirurgie und Medizin / CEA in Cyst-Fluid: What for ? Useful ? Mucinous vs. Non-mucinous (serous) Cut-off unclear: e.g. > 800 ng/mL No correlation with risk of malignancy

16 Universitätsklinik für Viszerale Chirurgie und Medizin / 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 Close surveillance alternating MRI with EUS every 3-6 months Strongly consider surgery (in young, fit patients) EUS in 3-6 months Lengthen interval, alternating EUS and MRI Consider surgery in young, fit patients (long surveillance) CT/MRI yearly (for 2 years) lengthen interval if no change

17 Universitätsklinik für Viszerale Chirurgie und Medizin / Which syndrome associates with multiple/ oligocystic SCN ? Hippel-Lindau-Syndrome


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