Case Presentation

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Case Presentation
Abdominal pain 53 yo woman presents with acute
epigastric pain radiates to her back associated
with nausea emesis No EtOH, trauma, new
meds RA, HTN, Cholecystectomy, C/S
CC HPI PMH
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Case Presentation
Remicade, Lodine, Altace, Methotrexate Codeine
Married, 20 ppd, occ EtOH Negative Negative
MEDS ALL SH FH ROS
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Case Presentation
226/110 84 20 98.6 NAD Anicteric CTA RRR
with flow murmur Epigastric pain w/o R/G No
c/c/e AOx3. Non-focal
Vitals Gen HEENT Lungs Heart Abd Ext Neuro
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Case Presentation
1157 NL 16,900 13.1 9.7 4.4 20 0.8 96
Lipase LFTs WBC HGB Ca Alb BUN Cr Tri
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Case Presentation
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Pancreatic Cystic Neoplasms

• Rajeev Jain, M.D.

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Cystic Lesions of the Pancreas
Congenital Cysts
Acquired Cysts
Primary Cystic Neoplasms
Nonpancreatic Lesions
Dermoid VHL Polycystic Simple
Adrenal cyst Biloma Choledochal Choledochocele Div
erticulum Duplication Mesenteric Retroperitoneal S
plenic artery aneurysm
Pseudocyst Parasitic Retention
Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
8
Primary Pancreatic Cystic Neoplasms

• Mucinous Tumors
• Cystadenoma
• Cystadenocarcinoma
• Intraductal papillary mucinous tumor (IPMN)
• Nonmucin Tumors
• Serous cystadenoma
• Solid-pseudopapillary tumor
• Cystic degeneration

• Acinar cell cystadenocarcinoma
• Angiomatous tumor
• Angioma
• Hemangioma
• Lymphangioma
• Islet cell tumors
• Lymphoepithelial cyst
• Pancreaticoblastoma
• Teratoma

Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
9
Epidemiology
TYPE GENDER AGE
Serous cystadenoma FgtM 60s 32-39
Mucinous cystic neoplasm FgtM 40s 10-45
IPMN MF 50s 21-33
Solid pseudo-papillary FgtM 30s lt10
Cystic endocrine neoplasm MF 40s lt10
Ductal adenocarcinoma with cystic degeneration MgtF 50s lt1
Acinar-cell cystadenocarcinoma MgtF 50s lt1
Brugge WR. et al. N Engl J Med.3511218-26.2004.
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Serous Cystadenoma

• Microcystic, serous, or glycogen-rich adenomas
• Presentation
• 50-60 have abdominal pain (up to 25 cm)
• 30 palpable mass
• Occ. obstructive jaundice, pancreatitis,
  pancreatic insufficiency, or gastric outlet obst.
• 25 small asymptomatic found on CT

Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
11
Serous Cystadenoma

• Focal, well-demarcated lesions
• Multiple (gt6), small (lt1-2 cm), fluid-filled
  microcysts
• Dense fibrous septations give honeycomb appearance

8 mm
Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
12
Serous Cystadenoma
Source www.jichi.ac.jp
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WHO Classification
Mucin-producing cystic neoplasms of the pancreas
Intraductal Papillary Mucinous Neoplasm (IPMN)
Mucinous cystadenoma
Mucinous cystadenocarcinoma
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Mucinous Cystadenoma

• Macrocystic adenoma
• Premalignant
• 25 contain malignancy at time of diagnosis
• Presentation
• Pain (60-80)
• Diabetes (25)
• Pancreatitis (10-20)
• Incidental (10-30)
• Ovarian stroma

Grogan JR et al. AJR 176921-9.2001.
Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
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Ovarian Stroma
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Intraductal Papillary Mucinous Neoplasm (IPMN)
Main Duct Variant Side
Branch Variant
Grogan JR et al. AJR 176921-9.2001.
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IPMN

• Presentation
• Pain (50-100)
• Acute pancreatitis (22-45)
• Asymptomatic (up to 30)
• Variants
• Main duct (47-75)
• Side branch (25-39)
• Both (14)

Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
18
Evaluation of PCNs

• 10-37 initially diagnosed erroneously as
  pseudocyst
• Delay in diagnosis
• Lost opportunity for curative resection
• Type of PCN
• Demographics
• Radiology
• EUS with FNA

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Imaging of PCNs
SCA MCN IPMN
Location Even Body/tail Head
TUS/CT/EUS
Septae Yes Yes No
Locularity Multi Multi Multi
Calcifications Central sunburst Peripheral curvilinear None
ERCP PD displaced PD displaced PD dilated mucin
Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
20
Serous CystadenomaCT Findings
Demos TC et al. AJR. 1791375-1388.2002.
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IPMN and ERCP
Aithal GP et al. Gastrointest Endosc.56(5)701-7.2
002.
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Pancreatic Duct
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IPMN Histology
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Pancreatic Cyst Fluid Analysis
Viscosity Amylase CA 19-9 CEA Cytology
Serous cystadenoma Low Variable Variable Low Glycogen
Mucinous cystadenoma High Variable Variable High Mucin
Mucinous cystadenoCA High Variable Variable High Mucin
IPMN High High Variable Variable Mucin
Pseudocyst Low High Variable Low Histiocytes
Levy MJ Clain JE. Clin Gastroenterol
Hepatol.2(8)639-53.2004.
25
Pancreatic Cyst Fluid Analysis

• 19 pancreatic cystic masses, 31 pseudocysts
• CA 19-9 gt 50,000 U/mL
• Sens 75, Spec 90
• MCN gt other cysts
• CEA lt 5 ng/mL
• Sens 100, Spec 86
• SCN gt other cysts
• Amylase gt 5,000 U/mL
• Sens 94, Spec 74
• Pseudocysts gt other cysts

Hammel P. et al. Gastroenterology.1081230-5.1995.

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Diagnosis of Pancreatic Cystic Neoplasms

• Multicenter trial
• 341 pts EUS-FNA
• 112 pts surgical resection
• Prospective evaluation
• EUS imaging,
• Cyst fluid cytology,
• Cyst fluid tumor markers
• CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3

Brugge WR. et al. Gastroenterology.1261330-6.2004
.
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Diagnosis of Pancreatic Cystic Neoplasms

• Accuracy
• CEA
• (88 of 111, 79)
• EUS morphology
• (57 of 112, 51)
• Cytology
• (64 of 109, 59)

Brugge WR. et al. Gastroenterology.1261330-6.2004
.
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Proposed Management Algorithm for Symptomatic PCNs
Scheiman JM. Gastroenterology.128463-9.2005.
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Proposed Management Algorithm for Asymptomatic
PCNs
Castillo, C. F.-d. et al. Arch Surg.138427-34.200
3.
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Pancreatic Cystic Neoplasm
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EUS Guided Cyst Aspiration
Amylase CEA CA 19-9
93 906 1,890,000
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Pancreatic Cystic Neoplasm
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Pancreatic Cyst
Amylase CEA CA 19-9
502 2.5 ----
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Case Presentation