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Cystic Neoplasms of the Pancreas O.Benjaminov Rabin Medical Center Beilinson Campus Paris 2008.

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Presentation on theme: "Cystic Neoplasms of the Pancreas O.Benjaminov Rabin Medical Center Beilinson Campus Paris 2008."— Presentation transcript:

1 Cystic Neoplasms of the Pancreas O.Benjaminov Rabin Medical Center Beilinson Campus 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

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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, 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 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:

7 Mucinous (macro) Neoplasms of the Pancreas

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11 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 ( cm) – avg. 10 cm. central stellate scar that can calcify (Ca=38%) Serous (micro) Cystadenomas of the Pancreas

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

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

19 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

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

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

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

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24 13/2/06 6/9/06

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26 2/2

27 Intarductal Papillary Mucinous Tumors of the pancreas (IPMT)

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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 cm Fibrous capsule, hemorrhage, necrosis

34 Cystic Neoplasms of the Pancreas Cystic degeneration

35 Cystic Neoplasms of the Pancreas

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37 Lymphoma

38 Incidentalomas Incidence % (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: Annals Surg 2004;239:651 AJR 2005;184:20-23 Am J Gastroenterol 2007; 102:

39 Algorithm for the management of incidental pancreatic cysts MGH 2003

40 Algorithm for the management of incidental pancreatic cysts Incidental Pancreatic Cyst < 1 cm Asymptomatic F/U US or CT 1 – 2.5 cm EUS & FNA Symptomatic & Asymptomatic >2.5 cm Surgery 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 Conclusions Cystic Neoplasms of the Pancreas 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

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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) % Intraductal Papillary Mucinous Tumor (IPMT) % Serous cystadenoma % Solid pseudopapillary tumor (SPT) < 10% Others are rare: acinar cell cancer < 1%

46 Cystic Neoplasms of the Pancreas Cystic Islet Cell Tumor

47 Pancreatic Metastases Cystic Neoplasms of the Pancreas

48 Cystic lymphangioma

49 Simple Cyst Mucinous Cyst PseudocystSerous Cyst

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51 Slide 13

52 Minerva Chir 2004; 59: Serous (micro) Cystadenomas of the Pancreas

53 Focal Pancreatitis FP/FP        

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