Pseudocyst of the pancreas and benign cystic neoplasms are two types of pancreatic cysts that can develop. Pseudocysts are collections of fluid that develop after pancreatitis and usually resolve on their own, but sometimes persist and cause complications. Benign cystic neoplasms include mucinous cystic neoplasms that are more common in women and involve mucin-producing epithelium, and intraductal papillary mucinous neoplasms which involve cystic growths and epithelial changes along the pancreatic ducts. Both conditions are generally diagnosed using imaging tests and investigated further if complications arise or if malignancy cannot be ruled out, with surgical resection as the treatment in some cases.

1. PSEUDOCYST OF PANCREAS AND
BENIGN CYSTIC NEOPLASMS
Dr. E.Kaushik Kumar
Stanley Medical College Hospital,Chennai

2. குறள் 84
அகனமர்ந்து செய்யாள் உறையும் முகனமர்ந்து
நல்விருந் த ாம்புவான் இல்
 விளக்கம்
மனமகிழ்ச்ெிறய முகமலர்ச்ெியால் காட்டி
விருந் ினறை வைதவற்பவர் வ ீட்டில் அமர்ந்து
செல்வம் எனும் ிருமகள் வாழ்வாள்

3.  Chronic Collection of amylase-rich fluid
enclosed in a non-epitheliazed wall of
fibrous(collagen) or granulation tissue.
 Follow after
 Acute Pancreatitis(5-15%)
 Chronic Pancreatitis(20-38%)
 Trauma
 4- 8 weeks from the onset of AP
 Single or multiple or multilobulated

4.  Duct leak
 Intrapancreatic or extend beyond into other
cavities or compartments
 Regress spontaneously 50%
 Chronic pseudocysts may persist
 Thick-walled or large (over 6 cm in diameter)
 Lasted for a long time (over 12 weeks)
 Arisen in the context of chronic pancreatitis

5. Symptoms and Complications
 Pain
 Fullness
 Satiety
 Loss of weight

6.  Complications include
 Abscess /systemic sepsis
 SMV/PV thrombosis
 Intracystic hemorrhage/pseudoaneurysms
 Peritonitis/intraperitoneal bleeding
 Pressure efects
 Pancreatico pleural fistula

7. INVESTIGATIONS
 Ultasonogram
 CT
 EUS
 ERCP
 MRCP
 FNA

8.  US,CT- Identification of pseudocyst and
differentiates from abscess
 EUS- Guided FNA Differentiates between
chronic pseudocyst and cystic neoplasms
 ERCP/MRCP- ductal communication,ductal
anomalies, chronic pancreatitis,plan
treatment

9.  CEA -High level in mucinous tumours
>400ng/ml
 Amylase- Level usually high in pseudocysts,
but occasionally in tumours
 Cytology- Inflammatory cells in pseudocyst

10. INTERVENTION
 Symptoms
 If complications develop
 Distinction has to be made between a
pseudocyst and a tumour

11. Internal drainage vs external drainage
 Endoscopic
 Percutaneous
 Surgical –Open/Laparoscopic

12.  Percutaneous
 Usually avoided
 Recurrence
 Pancreatico-cutaneous fistula

13. Endoscopic
 Distance of pseudocyst to the
gastrointestinal wall <1 cm
 Size>5 cm, gut compression, single cyst,
mature cyst, no disconnected segment of
pancreatic duct
 Symptomatic, failure with conservative
treatment, persistence over 4 weeks or
longer

14.  Location of transmural approach based on
maximal bulge of the pseudocyst to the
adjacent wall
 Mature cyst, perform pancreatography first,
prefer transpapillary approach, if feasible
 Check for debris within pseudocyst
 Neoplasm and pseudoaneurysm have to be
ruled out

15.  Surgical
 Complications
 Drainage internally
 Stomach
 Duodenum
 Jejunum
 Recurrence <5%

17. Newer techiques
 Forward-viewing echoendoscope
 PFC puncture devices
 Combination devices
 Devices for maintenance of cystenterostomy
 Multiple transluminal gateway technique
(MTGT)

19. CYSTIC NEOPLASMS
 Second most common neoplasm of exocrine
pancreas
 Mucinous cystic neoplasm
 Serous cystic neoplasm
 Intraductal papillary neoplasm

20. Mucinous cystic neoplasm
 Most common
 Histologic spectrum from benign to invasive
carcinomas.
 MCNs contain mucin-producing epithelium
 Mucin-rich cells and ovarian-like stroma
 Estrogen and progesterone staining are
positive in most cases.

21.  Frequently seen in young women, the mean
age at presentation is in the fifth decade.
 Men are rarely affected
 Body and tail of the pancreas
 Up to 50% of patients present with vague
abdominal pain.
 A history of pancreatitis may be found in up
to 20% of patients-common misdiagnosis of
pseudocyst

22.  CT Appearance
 Solitary cyst
 Fine septations
 Rim of calcification
 Malignant
 Large tumour size
 Egg-shell calcification
 Mural nodule

24.  Potential to turn to malignancy
 Resection
 Curative
 No further surveilance needed

25. Serous cystic neoplasm
 Higher median age
 Head of pancreas
 Vague abdominal pain,weight
loss,obstructive jaundice
 Large well circumscribed mass

26.  CT appearance
 Central calcification with radiating septa
 “Sun-burst” appearance
 Microscopic appearance
 Multiloculated,glycogen rich small cysts
 Resection
 >4cm
 Rapidly growing
 Diagnosis of malignancy is uncertain

27. Intraductal papillary mucinous
neoplasm
 6th-7th decade
 Wide spectrum of epithelial
changes,including benign adenoma,
borderline, carcinoma in situ, and invasive
adenocarcinoma
 Types
 Side branch
 Main duct
 Mixed

28.  Side branch IPMN
Involves dilation of the pancreatic duct side branches
that communicate with but do not involve the main
pancreatic duct.
 Focal/multifocal
 Malignant transformation directly
proportional to cystic dilatation
 10-15% risk

30. Main duct IPMN
 Abnormal cystic dilation of the main
pancreatic duct with columnar metaplasia
and thick mucinous secretions
 Focal or diffuse
 30%-50% risk of invasive cancer
 Surgical resection is the corner stone of
treatment –Partial Pancreatectomy

31.  50% present with abdominal pain
 25% present with AP
 Diagnostic confusion with – Chronic Pancreatitis
 Risk of malignancy
 Jaundice
 Elevated serum alkaline phosphatase level
 Mural nodules
 Diabetes
 Main pancreatic duct diameter of 7 mm

32. Mixed type
 Side branch IPMN that has extended to
involve the main pancreatic duct to a varying
degree
 Individuals with side branch cysts who exhibit
upstream dilation of the pancreatic duct
 Characteristics and management- similar to
Main duct IPMN

34. Conclusion
 Observation for patients with asymptomatic
small (<3 cm) branch duct IPMNs that have no
associated nodularity.
 A plan for watchful surveillance with delayed
intervention in these patients is reasonable
because
 Risks for malignancy with small, asymptomatic branch
duct tumors is low
 Most Patients are older
 Time required to develop invasive malignancy
>patient’s life expectancy.