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.
Pseudocyst of pancreas and benign cystic neoplasms
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
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
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
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
23.
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
29.
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
33.
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.