Cystic Neoplasms of the Pancreas Flashcards
Serous Cystic Neoplasm
- predilection for the head of the pancreas
- large, well-circumscribed masses.
- multiloculated, glycogen-rich small cysts.
- Central calcification, with radiating septa giving the sunburst appearance»_space; on CT
- considered Benign
- pancreatectomy If diagnosis of malignant disease is uncertain or in symptomatic serous cystadenomas
- ## larger than 4 cm are more likely to be symptomatic
Mucinous Cystic Neoplasm
- lack communication with the pancreatic duct.
- from benign to invasive carcinomas
- mucin-rich cells and ovarian-like stroma surrounding the cyst
- Staining for estrogen and progesterone
- seen in young women
- typically found in the body and tail
- presence of a solitary cyst, which may have fine septations and be surrounded by a rim of calcification
benign and malignant MCNs on CT
- the presence of eggshell calcification
- larger tumor size
- mural nodule
> > suggestive of malignancy
EUS and cyst fluid analyses for MCN
mucin-rich aspirate
high CEA levels (>192 ng/mL; log scale)
and low amylase.
Tx for MCN
- Pancreatic resection is the standard treatment for MCNs, given the potential for malignant transformation.
- In the absence of invasive malignant disease, resection is curative and no further surveillance is required
invasive MCNs, Adjuvant therapy ?
> > most centers offer adjuvant systemic chemotherapy after surgical resection, especially when node-positive disease is present
Intraductal Papillary Mucinous Neoplasm
- arise from the main pancreatic ducts or branch ducts or both
- Current histopathologic grading includes low, moderate, or high-grade dysplasia, and presence or absence of invasive malignancy
> > IPMN (BD-IPMN)
IPMN (MD-IPMN)
Mixed-type IPMNs.
Worrisome features of IPMN based on imaging
1- BD-IPMN cyst size larger than 3 cm
2- enhancing mural nodule smaller than 5 mm
3- thickened enhancing cyst wall
4- main pancreatic duct size of 5 to 9 mm
5- abrupt change in caliber of main pancreatic duct with distal pancreatic atrophy
6- lymphadenopathy.
7- pancreatitis
8- elevated CA19-9 level
9- cyst growth of more than 5 mm over two years
High-risk features of IPMN
- Presence of an enhancing nodule larger than 5 mm within the cyst
- Main pancreatic duct dilation of more than 1 cm.
- Clinical signs of jaundice
All cysts with worrisome features on CT or MRI
should undergo EUS
all cysts with high-risk features
should be resected
For asymptomatic patients with BD-IPMN who have no worrisome or high-risk features
> > surveillance may be a reasonable initial strategy
Based on size alone, asymptomatic patients with cysts larger than 3 cm (worrisome feature)
> > should be strongly considered for surgical resection
What about 2-3 cm , and Less than 2 cm ?
> > 2- to 3-cm cysts may be considered for resection or observation depending on age and physical condition
> > Cysts smaller than 2 cm generally have a low risk for malignancy and therefor are most appropriate for surveillance.
Any patient with symptoms or high-risk features related to BD-IPMNs (e.g., jaundice, enhancing mural nodule, and dilated main pancreatic duct) should undergo
> > should undergo surgical resection because the risk of malignant disease in symptomatic patients is heightened
risk of invasive malignant disease in the setting of BD-IPMN is approximately
> > Risk of invasive malignant disease in the setting of BD-IPMN is approximately 10% to 15%
> > The risk of invasive malignant disease is approximately 2% to 3% per year.
Main duct intraductal papillary mucinous neoplasm
- abnormal cystic dilation of the main pancreatic duct with columnar metaplasia and thick mucinous secretions
- can be seen oozing from a patulous papilla on endoscopic evaluation
- 30% to 50% risk of harboring invasive pancreatic cancer
- surgical resection is the cornerstone of treatment.
Predictors of malignancy
- jaundice
- elevated serum alkaline phosphatase level
- mural nodules
- diabetes
- main pancreatic duct diameter of 7 mm or larger
Worrisome Feature for MD IPMN
> > Current guidelines suggest that main duct dilation of more than 5 mm is consistent with a diagnosis of MD-IPMN and a worrisome feature,
high risk feature for MD IPMN
more than 1 cm is considered high risk.
All patients with evidence of MD-IPMN should be considered for
> > surgical resection if they are surgically fit.
The radiographic features of IPMNs on pancreatic CT scans
- dilated main pancreatic duct
- cysts of varying sizes
- possibly mural nodules
MCNs and BD-IPMNs, fluid aspirates characteristically reveal an elevated CEA level (>192 ng/mL; log scale), Why ?
> > is not predictive of invasive malignant disease
only the presence of mucinous metaplasia.
Mixed-type intraductal papillary mucinous neoplasm
As for MD-IPMN, surgical resection is indicated for the treatment of mixed-type IPMN.
Surgical Resection for Intraductal Papillary Mucinous Neoplasm
- Partial pancreatectomy is the primary treatment for high-risk lesions
- For BD-IPMN, resection should target the lesion of concern
- In the absence of diffuse polyps or enhancing nodules in the main duct, a right-sided pancreatectomy is preferred
- Intraoperative frozen section of the pancreas neck margin is obtained, and total pancreatectomy is reserved for those cases with high-grade dysplasia or invasive carcinoma identified at the margin
Following resection, what to do ?
> > surveillance of the remnant pancreas is advocated due to risk of recurrence of IPMN or invasive malignancy
> > Reoperation should be considered for patients who present with recurrence or progression of disease in the pancreas remnant
