[28] Pancreatic Cysts Flashcards
What are pancreatic cysts?
Collections of fluid that form within the pancreas
What is happening to the incidence of pancreatic cysts?
It is increasing
How are most pancreatic cysts identified?
Incidentally on imaging
What % of individuals going for an abdominal MRI scan will have an incidental pancreatic cyst identified?
Around 15%
What can pancreatic cysts be divided into?
True cysts (non-inflammatory) - what this deck is about Pseudocysts (inflammatory)
What can pancreatic cysts be classified based on?
Secretions
Histology
Risk of malignancy
What pancreatic cysts have a higher risk of malignancy?
Intraductal papillary mucinous neoplasms
Mucinous cystic neoplasms
Solid pseudopapillary neoplasm
Cystic pancreatic neuroendocrine tumour
What pancreatic cysts have a lower risk of malignancy?
Serous cystic adenoma
Simple cyst
Mucinous non-neoplastic cyst
Lymphoepithelial cyst
What are intraductal papillary mucinous neoplasms associated with?
Pancreatic duct malignancies
Where are intraductal papillary mucinous neoplasms often found?
At the main or branch pancreatic ducts
Where are mucinous cystic neoplasms often found?
In the body or tail of the pancreas
What % of mucinous cystic neoplasms are cancerous on diagnosis?
30%
What are the 70% of mucinous cystic neoplasms that are not cancerous on diagnosis considered to be?
Pre-cancerous
Who are solid pseudopapillary neoplasms most commonly found in?
Young Asian and Afro-Caribbean women
What is the prognosis of solid pseudopapillary neoplasms?
They have an excellent prognosis post-resection
What are the features of cystic pancreatic neuroendocrine tumours?
Rare
Frequently non-functional
Associated with MEN 1 syndrome
What are serous cystic adenomas?
Serous benign lesions
How do serous cystic adenomas typically look in imaging?
Honeycombed appearance
Where are serous cystic adenomas most commonly found?
In tail and body of pancreas
What is a simple cyst?
A true epithelial cyst, always benign lesions
What are mucinous non-neoplastic cysts?
Mucin producing lesions
Is dysplasia found in mucinous non-neoplastic cysts?
Rarely
How does a lymphoepithelial cyst appear on histology?
Sheets of lymphocytes, rarely with dysplastic cells associated
What % of cases of pancreatic cysts are asymptomatic?
70%
What are the presenting complaints for symptomatic pancreatic cysts?
Abdominal pain or back pain
Post-obstructive jaundice
Vomiting
How do symptomatic pancreatic cysts cause abdominal pain or back pain?
From mass effect or compression symptoms
How can pancreatic cysts present if they become infected?
They can present with systemic features
How can pancreatic cysts present if they become malignant and metastasise?
May present with systemic features of malignancy, e.g. weight loss, loss of appetite, change in bowel habits
What may be found on examination in pancreatic cysts?
Examination will likely be unremarkable, but on rare occasions there may be a tender abdomen, a palpable mass, or abdominal distention
What are the differential diagnoses for pancreatic cysts?
Pancreatic pseudocyst
What is a pancreatic pseudocyst?
A collection of fluid within the pancreatic tissue
When does a pancreatic pseudocyst typically form?
Following pancreatitis
Why may a pancreatic pseudocyst form following pancreatitis?
The inflammatory reaction produces a necrotic space in the pancreas that fills with pancreatic fluid
Why is a pancreatic pseudocyst so named?
Because it lacks epithelial or endothelial cells surrounding the collection
How are pseudocysts discovered?
They tend to be asymptomatic, so are usually picked up on imaging
What investigations may be required for pancreatic cysts being worked up for further management?
Baseline blood tests, including FBC, U&Es, and LFTs
CA19-9
Why might CA19-9 be done in pancreatic cysts?
To monitor progression of the disease
What do NICE guidelines suggest to further assess and evaluate pancreatic cysts?
Pancreatic protocol CT scan or magnetic resonance cholangiopancreatography
How can imaging be useful for determining prognosis?
It can be used to stratify those cysts that are low risk versus those that are high riks
What are the low risk features of pancreatic cysts that can be seen on imaging?
Cyst diameter <3cm
Cystic morphology with central calcification
(Asymptomatic)
What are the high risk features of pancreatic cysts that can be seen on imaging?
Cyst diameter >3cm
Main pancreatic duct dilation greater than 10mm
Enhancing solid component
Non-enhancing mural nodule
What may be warranted based on features identified on initial imaging in pancreatic cysts?
Further investigations, either via complete resection (especially if high risk, or further testing through endoscopic US scan with fine needle aspiration
Why is endoscopic US scan with fine needle aspiration done in pancreatic cysts?
It allows for a biopsy sample to be obtained, which is useful in determining both low and high grade lesions
What is the purpose of discussion of pancreatic cysts in the MDT?
To plan for any further imaging, follow-up, or surgical intervention
What is true of the majority of pancreatic cysts?
They are benign, and can therefore be left alone with surveillance only
What is the first-line treatment for high-risk pancreatic cysts?
Resection, where feasible
How are high-risk pancreatic cysts followed up after resection?
In most cases, follow-up MRI scan every 2 years
How often is surveillance done in low-risk pancreatic cysts?
5 yearly
What should be done if there is any rapid growth or suspicions during surveillance for pancreatic cysts?
The cyst should be re-investigated and managed appropriately
What is the prognosis of pancreatic cysts?
Highly dependant on the subtype of the cyst, and the degree of invasion
