Evaluation and Management of Pancreatic Cystic Lesion Using Endoscopic Ultrasound

1
Evaluation and Management of Pancreatic Cystic
Lesion Using Endoscopic Ultrasound
Praveen Sateesh, M.D., M.H.S.A. Department of
Medicine, Georgetown University Hospital,
Washington, DC
Georgetown University
Introduction
EUS/ FNA findings of Pancreatic Cystic Lesions
The differential diagnosis of pancreatic cystic
lesions include congenital cyst, acquired cysts
which include pseudocysts (accounting for 80-90
of all panreatic cysts), extrapancreatic cysts,
and cystic pancreatic tumors. CPTs are an
important group to identify and compromise 10-20
of all cystic pancreatic lesions. The most common
cystic pancreatic tumors (CPTs) include serous
cystadenomas, mucinous cystic neoplams (mucinous
cystic adenomas and cystadenocarcinomas), and
intraductal papillary mucinous neoplasms. Early
detection is important in terms of patient
outcomes. Detection is important even after
malignancy has developed because surgical
resection has a relatively high cure rate. A
potent technology, EUS can be an extremely
valuable tool in the evaluation and management of
CPTs.
Cystic Pancreatic Tumors
CPTs are classified broadly according to their
malignant potential. Mucinous and IPMNs and
premalignant or malignant and surgical resection
is generally recommended. Nonmucinous CPTs
include serous cystadenomas with very low
malignant potential and surgical resection is
restricted to those inducing symptoms or
complications. Serous cystadenomas These are
glycogen rich. Typically diagnosed in women in
the 7th decade of life. Abdominal pain is the
common presenting symptom. They can grow up to
25cm and can be a palpable mass in 30 of
patients. Obstructive jaundice, pancreatitis,
pancreatic insufficiency, or gastric outlet
obstruction are further complications. Mucinous
cystic neoplasms These are all premalignant with
25 containing malignancy at the time of
diagnosis (mucinous cystadenocarcinomas).
Mucinous cystic adenomas are diagnosded in women
in the 5th or 6th decade of life and
cystadenocarcinomas are diagnosed on average 10
years later. Abdominal pain is the most common
complaint. Weight loss and jaundice may herald
the onset of malignancy. Intraductal papillary
mucinous neoplasms These arise from the
epithelium of the main pancreatic duct and/or its
side branches. They are characterized by
papillary epithelial growth, mucin
overproduction, ductal dilitation, and malignant
potential. Main duct IPMN occurs mainly in men
in the 6th or 7th decade of life. Side duct IPMN
occurs with no gender preference. Abdominal pain
and acute pancreatitis are the main clinical
presentations. Approximately 1/3 are
asymptomatic at the time of diagnosis.
Retrospective Study
The preoperative diagnosis of pancreatic cystic
lesions remains difficult and there are still no
established guidelines in their evaluation and
management. We have identified cases of cystic
pancreatic lesions identified by CAT scan or MRI
which have had further evaluation with endoscopic
ultrasound. These cases have also undergone fine
needle aspiration of the cystic lesions with
samples sent for amylase, CEA, and
cytology. This study is designed to evaluate the
performance of the EUS and FNA findings in the
diagnosis of cystic pancreatic lesions and
specifically CPTs using surgical pathology
results as the benchmark for comparison. Currentl
y we are still in the data collection stage. We
have no publishable results as of yet.
Endoscopic Ultrasound
Endoscopic Ultrasound combines endoscopy and
ultrasound in obtaining images and information of
the GI tract and surrounding tissues and organs.
EUS is ideally suited to evaluate cystic lesions
due to its ability to apply the ultrasound
transducer at the tip of the endoscope against
the duodenal or gastric wall enhancing imaging
quality. Furthermore, EUS allows for ease of fine
needle aspiration of these structures. Color
flow and doppler are used to identify and help
avoid vascular structures.
Data Collection
We are currently obtaining cases by searching the
Georgetown University Hospital Division of
Gastroenterology EndoPro database. We are
differentiating cases based on cyst size,
location, and EUS characteristics. For each case
that has undergone EUS and FNA we are obtaining
1) lab values for amylase and CEA, 2) cytology
results, 3) surgical pathology results for those
cysts which have been resected, and 4) six month
clinical follow up information after EUS and FNA.
Acknowledgements
Nadim G. Haddad, M.D., Associate Professor,
Director of Fellowship, Georgetown University
Hospital Department of Gastroenterology.