Transcript CYSTIC TUMORS OF THE PANCREAS

CYSTIC TUMORS OF THE
PANCREAS
A.R.Fahim,M.D
5,day,92
• Less than 10% of pancreatic neoplasms
• Results of 24,000 abdominal CT and MRI during
8-year period:
pancreatic cysts in 1.2% of patients
60% cystic neoplasms
• MCNs, serous cystadenomas, and IPMNs
comprise more than 80%
• Masquerade as pancreatic pseudocysts
• High cure rate following surgical treatment
DIFFERENTIAL DIAGNOSIS
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Exclusion of a pancreatic pseudocyst:
lack an epithelial lining
history of acute or chronic pancreatitis, or
abdominal trauma
lack of septae, loculations, solid components,
or cyst wall calcifications on CT or MRI
communication between the cyst and the main
pancreatic duct
high levels of amylase
Does require surgical resection?
• Slow growing, and favorable prognoses
• Tumors with malignant potential include
MCNs, IPMNs, solid pseudopapillary tumors
(SPTs), and cystic islet cell tumors
• Serous cystadenomas are almost universally
benign
• Many of these cysts are very small (<2 cm)
• Nonoperation
• Operation:
older than 70 years
new symptoms
cyst growth on serial imaging
DIAGNOSTIC IMAGING
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CT
MRI
ERCP
EUS
PET
Cyst Fluid Analysis in Cystic Lesions of
the Pancreas
SEROUS
MCNPARAMETER PSEUDOCYST CYSTADENOM MCN-BENIGN
IPMN
MALIGNANT
A
Viscosity
Low
Low
High
High
High
Amylase
High
Low
Low
Low
CEA
Low
Low
High
High
CA 72-4
Low
Cytologic
findings
Histiocytes
High
High
Intermediate
Low
Intermediate High
to high
Columnar
Columnar
Cuboidal cells
mucinous
mucinous
with
Adenocarcino
epithelial cells
epithelial cells
glycogen-rich
ma cells
with variable
with variable
cytoplasm
atypia
atypia
MUCINOUS CYSTIC NEOPLASMS
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10% to 45%
Thick-walled with occasional septations
Filled with thick mucous or hemorrhagic material
Benign, borderline, or malignant
(cystadenocarcinoma)
• All these tumors should be treated as
premalignant lesions
• Ovarian-type stroma
• Almost exclusively in women
• Confined to the distal pancreas (body and tail
of the gland)
• Never multifocal
• Mean age is 50 years
• Abdominal pain or a palpable mass
• Incidental:25%
• MCN should be suspected when a CT or MRI
of the abdomen shows a cyst within the body
or tail of the pancreas in a middle-aged
woman
• No communication between the pancreatic
duct and the cyst itself
• EUS can identify septations and cyst wall
nodules and allows cyst wall biopsy and cyst
fluid aspiration
Cyst Fluid Analysis in Cystic Lesions of
the Pancreas
SEROUS
MCNPARAMETER PSEUDOCYST CYSTADENOM MCN-BENIGN
IPMN
MALIGNANT
A
Viscosity
Low
Low
High
High
High
Amylase
High
Low
Low
Low
CEA
Low
Low
High
High
CA 72-4
Low
Cytologic
findings
Histiocytes
High
High
Intermediate
Low
Intermediate High
to high
Columnar
Columnar
Cuboidal cells
mucinous
mucinous
with
Adenocarcino
epithelial cells
epithelial cells
glycogen-rich
ma cells
with variable
with variable
cytoplasm
atypia
atypia
• Classification :
benign adenomas (72%)
borderline neoplasms (10.5%)
carcinoma in situ (5.5%)
invasive cancer (12%)
• Malignant MCNs
larger than benign counterparts (80 vs.
45 mm)
more likely to harbor nodules within their
walls
• Surgical resection is advocated for all of them
• Distal pancreatectomy with or without
splenectomy
• Laparoscopic approach is acceptable
• Lymph nodes metastases are rare
• Given that MCNs are never multifocal, longterm surveillance is not required for patients
with resected noninvasive tumors
SEROUS CYSTADENOMAS
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Microcystic adenoma
Second most common
Women (75%)
Mean age of 62 years
Most (50% to 70%) occur in the body or tail
Association with von Hippel-Lindau disease
Vague abdominal pain and discomfort,
palpable mass,incidental
• Numerous tiny cysts separated by delicate
fibrous septa, giving them a honeycomb
appearance
• The cysts are filled with clear watery fluid and
are often arranged around a central stellate
scar that may be calcified
• Spongy mass with a central “sunburst”
calcification in CT:10%
Cyst Fluid Analysis in Cystic Lesions of
the Pancreas
SEROUS
MCNPARAMETER PSEUDOCYST CYSTADENOM MCN-BENIGN
IPMN
MALIGNANT
A
Viscosity
Low
Low
High
High
High
Amylase
High
Low
Low
Low
CEA
Low
Low
High
High
CA 72-4
Low
Cytologic
findings
Histiocytes
High
High
Intermediate
Low
Intermediate High
to high
Columnar
Columnar
Cuboidal cells
mucinous
mucinous
with
Adenocarcino
epithelial cells
epithelial cells
glycogen-rich
ma cells
with variable
with variable
cytoplasm
atypia
atypia
• Benign
• Surgical resection is the treatment of choice
for symptomatic lesions
• Observation if asymptomatic.
• Observation carries the risk of continued
growth, which may lead to complications such
as hemorrhage, obstructive jaundice,
pancreatic insufficiency, or gastric outlet
obstruction
• Tumors larger than 4 cm: resction
INTRADUCTAL PAPILLARY MUCINOUS
NEOPLASMS
• IPMNs represent papillary neoplasms within
the main pancreatic duct
• Benign (adenoma), borderline, or
malignant(60%)
• Lymph node metastases( 33% to 51%)
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Men=women
Median age 65 years
Abdominal pain and weight loss
Recurrent pancreatitis: 20%
Acute pancreatitis:25%
Malignant neoplasms:older,jaundice or newonset diabetes
• CT or MRI: dilation of the pancreatic duct
• ERCP:patulous ampulla of Vater with
extruding mucus(fish mouth)
main duct dilation
filling defects due to viscid mucus or
tumor nodules
communication between cystic areas
and the main pancreatic duct
• Pancreaticoduodenectomy
• Distal pancreatectomy
• Total pancreatectomy
SOLID PSEUDOPAPILLARY TUMORS
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Less than 10% of the cystic tumors
Women:men (10 : 1 ratio)
Disease of young women in their 30s
Abdominal pain:50%
Large abdominal mass:35%
Incidental:15%
Body and tail:60%
• Carcinoma:20%
• Complete loss of E-cadherin expression in the
cells or abnormal localization of E-cadherin to
the cell nucleus:100%
• Very slow-growing
• Complete resection