69 year old male patient, presented to emergency department for three week history of jaundice, pruritis, pale stools and dark urine.

1. Case presentation
Georges Khalifeh
PGY3 General surgery
Lebanese University

2. Case Presentation
CC
HPI
JAUNDICE
69 yo male patient, presented to ER
for three-week history of jaundice,
pruritus, pale stools and dark urine.
associated with nausea & emesis
No EtOH, trauma, new meds
C/S

3. Case Presentation
MEDS
PMH
ALL
FH
LOSANET APOALUPRINOL
CALTRAT ONE ALFA
HTN,GOUT CKD
NKFDA
Negative

4. Examination
Vitals
HEENT
Lungs
Heart
Ext
Neuro
Stable
ICTERUS
GBAE
Reg S1S2
No LLE
CCOx3.

5. Abdominal exam
Soft abdomen
Minimal abdominal tenderness.
Murphy –
Courvoisier sign +
Audible bowel sounds

6. Investigations
Hg 9,8
Ht 26
Bilirubin 8.78 /5.41
e- nl
Lipase 200
Amylase 112
Ph al 220
Alt 148/ Ast 196/Ggt 404

7. What to do ..

8. Echo abdominal

10. Echo abdominal
 Distended gallbaldder
 Microlithiasis
 Dilatation of biliary tree(intra extrahepatic)
 Cbd 11 mm

11. What to do ..

12. Ct scan
abdomino pelvien +contraste

14. Ct scan
abdomino pelvien +contraste
 Hypodense lesion at the level of head neck
and tail of the pancreas
 Dilatation of wirsung

15. Tumor marker
CA 19 9 : 142.88

16. What to do

17. MRCP

19. MRCP
Cystic formation in continuity with wirsung duct
 Head of the pancreas 2 cm
 Tail of the pancreas 4cm
Wirsung 3 mm

20. Differential diagnosis

21. Cystic lesion in pancreas
 Is this lesion from pancreas?
 Lesion is solid or cystic?
 Neoplastic v/s non neoplastic

22. Pancreatic
Cyst

23. While approaching a cystic
lesions we need to know
 Broad differential diagnosis
 Epidemiology of common lesions
 Clinical presentation
 Blood tests
 Imaging
 histology

25. Serous Cystadenoma
 Considered benign neoplasms originating from
centro-acinar cells
 Comprised of multiple fluid-filled cysts (microcystic
adenoma)
 Historically found in women in seventh decade
 Arise in any region of the pancreas

26. Serous Cystadenoma
Source: www.jichi.ac.jp

27. SCA Imaging features
 Focal, well-demarcated
lesion
 20% have a central scar or
“sunburst” calcification
CT EUS
 Lobular macro- and
microcystic lesion with
a honeycomb
appearance

28. Serous Cystadenoma
 Very low malignant potential
Management
 Asymptomatic lesions can be observed
 Resection for symptoms

29. Solid Pseudopapillary Tumors
Rare neoplasms – malignant potential has not
been well studied
Growth rate can be dramatic
Historically diagnosed in women in their 20’s-30’s
Typical presentation: abdominal mass

30. Solid Pseudopapillary Imaging
features
 Solid and cystic mass with occasional calcifications
CT EUS

31. Solid Pseudopapillary Tumors
Management
With the excellent prolonged survival and chance for cure
along with the inability to reliably predict malignancy
operative resection is recommended

32. Mucin-producing cystic neoplasms of the pancreas
Mucinous cystadenoma
Mucinous cystadenocarcinoma
Intraductal Papillary
Mucinous Neoplasm
(IPMN)

33. Mucinous Cystic Neoplasms
Neoplasm that secretes mucin, but does not
communicate with the pancreatic duct
Affects women, usually in the 5th to 7th decade
Predominantly in the body/tail

34. MCN Imaging features
 Unilocular or septated cyst that may include wall
calcifications typically in the body/tail
CT EUS

35. Mucinous Cystic Neoplasms
Management
 For patients deemed at appropriate surgical risk,
operative resection is recommended due to the risk
of malignancy
 Surveillance is not recommended after resection
 For small lesions in patients deemed to be at a
higher surgical risk, follow-up is not recommended

36. IPMN
 First described in 1982,it is characterized by
papillary proliferation of mucin producing
epithelial cells with excessive mucus
production and cystic dilatation of main or
branch pancreatic ducts
 2/3 are man
 Peak age 60-70

37. IPMN
 Variants
 Main duct (47-75%)
 Side branch (25-39%)
 Both (14%)

38. Intraductal Papillary Mucinous
Neoplasm (IPMN)
Main Duct Variant Side Branch Variant

39. Indication for surgery
 Main duct and mixed variant IPMN =>
RESECTION
 Branch duct IPMN=>
 Symptomatic (30% malignancy)
 >3 cm in size
 Mural nodules

40. Management after resection for
IPMN
 Noninvasive IPMN (adenoma, dysplasia), 0-10% risk
of recurrence in remnant gland
 Invasive IPMN, risk of recurrence is 50-90%
 Recurrence rates are similar for invasive IPMN after
partial pancreatectomy (67%) or total pancreatectomy
(62%)
Surveillance needs to be performed after
resection of IPMNs, but the interval and modality
remains unclear

41. Follow up plan
 Slow growing
 Residual tumor may develop into carcinoma
 New IPMN arise from remnant
 Time of recurrence ranged from 8-62 months
=> need regular FU imaging

42. Our patient has ..
 No clear cut diagnosis on history
 Serum markers were non informative
 Imaging non diagnostic
What next

43. EUS
 EUS +/- FNA is indicated to further assess
and categorize cystic pancreatic lesions

44. EUS Morphology
.
• Cyst wall
– Thick vs. thin
• Solid component
• Associated with malignancy
• Septations
– Micro vs. macrocystic
• Ductal abnormalities
• Main duct vs. side duct
• Number of cyst
• Lymphadenopathy
• EUS morphology can correctly differentiate mucinous
from non-mucinous cystic lesions approximately 50% of
the time

45. Pancreatic Cyst Fluid Analysis
CA 19-9 > 50,000 U/mL
 Sens 75%, Spec 90%
 MCN > other cysts
CEA < 5 ng/mL
 Sens 100%, Spec 86%
 SCN > other cysts
Amylase > 5,000 U/mL
 Sens 94%, Spec 74%
 Pseudocysts > other cysts

47. Coming back to our case

48. EUS
 Therefore EUS guided FNA was done

49. EUS
Head of the pancreas :
 30 mm by 29 mm hypoechoic solid mass
 Contained small amounts of sludge
 Did not invade vessels
 Suggestive of a malignant process
 FNA performed and sent to cytology

50. EUS
Tail of the pancreas
 No mass seen
 45 mm cystic lesion
 Cyst was aspirated ,clear thin fluid sent for
fluid analysis (CEA ca19 9 amylase lipase)
 And for cytology
 Another smaller cystic lesion in the neck of
the pancreas

51. EUS
 Appearance is suggestive of a malignant
mass in the head of the pancreas with
possible IPMN versus dilated duct and cystic
dilatation due to obstruction

52. Histopathology

53. Microscopie
Kyste de la queue du pancreas:
 Cellularite tres faible ,peu contributive
 Cytologie: elements epars de cellules
regulieres
 Les colorations de PAS et de alcian sont
negatives

54. Microscopie
Tete du pancreas:
 Cellularite :abondante et contributive
 Cytologie: population formee par des elemets
monomorphes a noyaux reguliers de petite taile
disposes en placards cohesif au sein d’un
substract vraisemblablement mucineux
 Les colorations de PAS et bleu alcian sont positifs

55. Conclusion
kyste de la queue du pancreas /FNA
 Materiel tres peu cellulaire non contributif.
tete du pancreas /FNA
 Absence de signe de malignite
 Materiel cytologique compatible avec une
lesion benigne vraisemblablement mucineuse

56. PANCREATIC FLUID
LIPASE : very high cannot be analyzed
Amylase body fluid :19572 U/L
CEA 268.18 ng/mL
CA 19 9: >12000 U/Ml

57. Summary
 No single test or imaging modality can reliably
differentiate cyst type
 Composite data is needed
 Clinical features of the patient
 Cross-sectional imaging
 Tumor markers
 EUS with cyst fluid analysis

58. Key points

59.  patient was referred to surgical oncology for
consideration of Whipple procedure

60. Whipple
procedure

61.  Under GA
 Supine position

62. Subcostal insicion down to the
peritoneum

63.  Exploration revealed ascites but no peritoneal
carcinomatosis or liver metastasis
 Peritoneal fluid for cytology was taken

64.  Dissection of the gastrocolic ligament away from
the transverse colon leading to the lesser sac
 Identification of the vein of henley, following the
vein lead us to the neck of the pancreas
 Palpation of the pancreas revealed multiple
enlarged cysts all over the gland

65.  Dissection posterior to the pancreas at the level of the
junction between the neck and body until a tunnel was
created from the inferior to the superior border of the
pancreas

67.  Opening of the gastrohepatic ligament and
dissection of the common hepatic artery and
hepatic artery proper
 Ligation of the gastroduodenal artery and the right
gastric artery

68.  kocherization was performed
 Identification of multiple small bowel
diverticula on the jejunum

70.  Decision was made to resect a longer jejunal loop
incorporating those diverticula with the specimen

71.  The duodenum and the resected portion of
the jejunum were brought to the upper
abdomen through the ligament of treitz

72.  Stomach was cut with the GIA at the level of
the antrum ,staple line was oversewn with
00vicryl

74.  Dissection of the porta hepatis and portal
adenectomy was perfomed
 Cholecystectomy by first ligating the cystic
duct and artery
 Removing the gallbladder from its bed
 Division of the CBD

75. Proper
hepatic
CBD

77.  Division of the pancreas at the junction
between neck and body
 Dissection and removal of the soft tissue
posterior to the head of the pancreas
 Taking care to ligate any branches coming
from the portal vein
 Removal of the specimen

79.  Creation of a window in the transverse
mesocolon through which the jejunal loop was
brought through to reach the upper abdomen

80.  Creation of the pancreatojejunostomy with
interrupted 4 0 prolen, End to side ,whole-
thickness
 10 cm distally , hepaticojejunostomy using 4 0
vicryl
 60 cm distally ,creation of a stapled
gastrojejunostomy

82.  Closure of mesenteric defect
 Insertion of two corrugated drains
 Closure of the abdomen

84. Pancreatic cyst fluid
 CEA level was the gold standard to
differentiates mucinous from no mucinous
cysts

86. Cyst fluid samples from 153 patients were
evaluated
 mucinous: 25 mucinous cystic neoplasms, 77
IPMN, 4 ductal adenocarcinomas;
 nonmucinous: 21 serous
 cystic neoplasms, 9 cystic neuroendocrine
tumors,
 14 pseudocysts,
 3 solid pseudopapillary neoplasms

89.  Median cyst fluid glucose was lower in
mucinous versus nonmucinous cysts
(19 vs 96 mg/dL; P < .0001)

91. ≤ 50 mg/dL, cyst fluid glucose was 92% sensitive,
87% specific, and 90% accurate in diagnosing
mucinous pancreatic cysts.
In comparison, cyst fluid carcinoembryonic antigen
with a threshold of >192 ng/mL was 58%
sensitive, 96% specific, and 69% accurate.

92. Conclusions
 Pancreatic cyst fluid glucose differentiates
mucinous from no mucinous cysts with similar
accuracy to the current “gold standard”
CEA.

93. Pancreatic cyst fluid glucose
 advantages :
 Simple
 Rapid
 Inexpensive
 requires minimal cyst fluid.

94. Conclusions
 cyst fluid glucose should routinely be tested to
aid in the diagnosis of mucinous pancreatic
cysts.

95. Conclusions
 Combining CEA and glucose improves
diagnostic accuracy and may further
approach perfection if evaluated together with
additional biomarkers, clinical factors, and
imaging characteristics.

96. THANK YOU