Cystic neoplasm of pancreas

1. Cystic Neoplasm of
Pancreas
Dr. Diwan Shrestha
MS Resident

2. Introduction
• Second most common exocrine pancreatic neoplasm
• Relatively rare neoplasm
• 1% of all panceatic neoplasm
• 10% of all cystic lesions of pancreas

3. WHO classification of
pancreatic cystic neoplasms
1. Serous cystic neoplasm (SCN)
 Serous microcystic adenoma
 Serous macrocystic adenoma
 Serous oligocystic adenoma
 Serous cystadenocarcionoma
2. Mucinous cystic neoplasm (MCN)
 Mucinous cystadenoma
 Mucinous cystic neoplasm with moderate dysplasia
 Mucinous cystadenocarcinoma

4. WHO classification of
pancreatic cystic neoplasms
3. Intraductal papillary mucinous neoplasm (IPMN)
 Intraductal papillary mucinous adenoma
 Intraductal papillary mucinous neoplasm with moderate dysplasia
 Intraductal papillary mucinous carcinoma
4. Solid pseudopapillary neoplasm
 Solid pseudopapillary neoplasm
 Solid pseudopapillary carcinoma

5. Types of Cystic Neoplasm
• 3 most common type :
 SCN
 MCN
 IPMN
• Represent approx 90% of all PCNs
• MCN & IPMN
 Have the highest potential for malignant transformation
• SCN
 Almost always benign

6. Serous cystic neoplasm
• Female to male ratio (3:1)
• Average age 62 years
• Common in the head of pancreas
• Commonly present with vague abdominal pain
 Less frequently with weight loss and obstructive jaundice
• On gross inspection
 Large, well circumscribed mass
• Microscopic examination
 Multiloculated, glycogen-rich small cysts

7. Serous cystic neoplasm
• Central calcification with
radiating septa giving the
sunburst appearance
 Radiographic sign on CT
 10% to 20% of patients
• Tumor larger than 4 cm
more likely to be
symptomatic
 display a more rapid median
growth rate

8. Mucinous cystic neoplasm
• Most common cystic neoplasms of the pancreas
• Common in perimenopausal women
• Men rarely affected
• Mean age at presentation fifth decade
• Typically found in the body and tail of the pancreas
• Incidental MCN becoming increasingly common

9. Mucinous cystic neoplasm
• 50% patients present with vague abdominal pain
 30% have palpable abdominal mass
• History of pancreatitis may be found in up to 20% of
patients
• Tumors span the histologic spectrum from benign to
invasive carcinomas
 < 20% MCNs associated with invasive carcinoma
• MCNs contain mucin-producing epithelium
 Identified histologically by the presence of mucin-rich cells and ovarian-like
stroma

10. Mucinous cystic neoplasm
• CT scan
 Presence of a solitary cyst
 May have fine septations
 Surrounded by a rim of calcification
• Cross-sectional imaging
may not be able to
distinguish between benign
and malignant MCNs
 Presence of eggshell calcification
 Larger tumor size
 Mural nodule
 Suggestive of malignancy

11. Mucinous cystic neoplasm
• FNA with cyst fluid analysis of MCNs demonstrate
 Mucin-rich aspirate
 High CEA levels (>192 ng/mL)
• MCNs typically have low levels of cyst fluid amylase
• Stroma cells stain
 Estrogen (25-63%)
 Progesterone ( 50-80%)
 Alpha-inhibin (50-70%)
• Invasive MCNs exhibit
 Slower growth
 Less frequent nodal involvement
 Less aggressive clinical behavior
 Compared with ductal adenocarcinoma

12. Intraductal papillary mucinous
neoplasm
• First recognised in 1982 by Ohashi
• Defined as intraductal, grossly visible epithelial
neoplasm of mucin producing cells
• Approx 3-5% of all pancreatic tumors
• Peak incidence at 60-70 years
• More prevalent in males than female

13. Intraductal papillary mucinous
neoplasm
• Can be 3 types :
1. Main duct IPMN
 Approx 25% of IPMNs
 Segmental or diffuse dilation of MPD (>5mm) in the absence of other
causes of ductal obstruction
 MPD is mucin filled & tortous
 Common near the head of pancreas
 Adjacent pancreas can be fibrotic & firm due to chronic pancreatitis
 MD-IPMN have a 30% to 50% risk of harboring invasive pancreatic
cancer at the time of presentation

14. Intraductal papillary mucinous
neoplasm
2. Branch duct IPMN
 Approx 57% of IPMNs
 Involves dilation of the pancreatic duct side branches that
communicate with but do not involve the main pancreatic duct
 May be focal, involving a single side branch, or multifocal, with
multiple cystic lesions throughout the length of the pancreas
 Occur in slightly younger population
 Common in uncinate process
 Less associated with malignancy
 Grossly appear as grape like structure that are multicystic containing
mucin filled ducts
 Adjacent pancreas usually normal due to non involvement of main
pancreatic duct

15. Intraductal papillary
mucinous neoplasm
3. Mixed type IPMN
 Approx 18% of IPMNs
 A side branch IPMN that has extended to involve the main pancreatic duct
to a varying degree
 Meet criteria for both main & branch duct IPMN

16. Intraductal papillary mucinous
neoplasm
• Majority of IPMNs discovered incidentally
 Mostly asymptomatic
• When symptoms do occur
 Tend to be non specific
 Unexplained weight loss, abdominal pain, anorexia
 Jaundice due to mucin obstructing ampulla
 Obstruction of pancreatic duct can cause pancreatitis

17. Intraductal papillary mucinous
neoplasm

18. Intraductal papillary mucinous
neoplasm
• Triad of Ohashi
 Bulging ampulla of Vater
 Mucin secretion from patulous papilla
 Dilated main pancreatic duct

19. Intraductal papillary mucinous
neoplasm
• IPMNs based on epithelial lining of papillary component
categorised into
 Gastric
 Intestinal
 Pancreaticobiliary
 Oncocytic
• Branch duct IPMN mainly of gastric variant
• Main duct IPMNs mainly intestinal type

20. Intraductal papillary
mucinous neoplasm
• All cysts with worrisome
features on CT or MRI
and any cyst larger than
3 cm with or without
worrisome features
should undergo EUS
• All cysts with high-risk
features should be
resected

22. Management
Serous cystic neoplasm
• Nearly all SCNs are benign
• In older or frial patients
 Conservative approach
• Indications for operative management
 Presence of symptoms
 Cyst > 4 cm
 Uncertainty of diagnosis despite appropriate radiological assesment

23. Serous cystic neoplasm
• Type of surgical resection
 Based on position of cyst within the pancreas
• Can be
 Anatomic pancreatectomy ( pancreaticoduodenectomy or distal
pancreatectomy)
 Tissue preserving procedure ( segmental central pancreatectomy)
• No role for lymphadenectomy or extended resections
 Due to inherent benign nature

24. Mucinous cystic neoplasm
• Surgical resection irrespective of location in the
pancreas or size
• MCN in the head of pancreas
 Pancreaticoduodenectomy
• MCN in the body & tail of pancreas
 Distal pancreatectomy
• Concurrent splenectomy controversial
• Lymph node excision limited to immediate proximity of
pancreatic lesion

25. Intraductal papillary mucinous
neoplasm
• IPMN localised to body & tail
 Distal pancreatectomy with splenectomy
• IPMN localised to head or uncinate process
 pancreaticoduodenectomy

28. Intraductal papillary mucinous
neoplasm
• Endoscopic cyst ablation using ethanol or in combination
with Paclitaxel can be done
• Ablation can be done for
 Small cysts
 Patients with serous comorbidities
• Endoscopic ablation with ethanol contraindicated in
main duct IPMN
 Due to interaction of ethanol with the activation of zymogens resulting in acute
pancreatitis

29. Adjuvant therapy
• Patients with evidence of invasive disease on final
pathology even in the absence of positive margins
• Gemcitabine based chemotherapy with radiotherapy

30. Surveillance
• Modality of choice MRI
• CEA & CA 19-9 has
limited role for detection of
IPMN recurrence

31. THANK
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