Transcript Case Presentation CC Abdominal pain HPI 53 yo woman presents with acute epigastric pain radiates to her back associated with nausea & emesis No EtOH, trauma, new meds PMH RA,

Case Presentation
CC
Abdominal pain
HPI
53 yo woman presents with
acute epigastric pain
radiates to her back
associated with nausea & emesis
No EtOH, trauma, new meds
PMH
RA, HTN, Cholecystectomy, C/S
Case Presentation
MEDS
ALL
Remicade, Lodine, Altace,
Methotrexate
Codeine
SH
Married, 20 ppd, occ EtOH
FH
Negative
ROS
Negative
Case Presentation
Vitals
Gen
HEENT
Lungs
Heart
Abd
Ext
Neuro
226/110 84 20 98.6
NAD
Anicteric
CTA
RRR with flow murmur
Epigastric pain w/o R/G
No c/c/e
A&Ox3. Non-focal
Case Presentation
Lipase
LFTs
WBC
HGB
Ca
Alb
BUN
Cr
Tri
1157
NL
16,900
13.1
9.7
4.4
20
0.8
96
Case Presentation
Pancreatic Cystic
Neoplasms
Rajeev Jain, M.D.
Cystic Lesions of the Pancreas
Congenital
Cysts
Acquired
Cysts
Dermoid
VHL
Polycystic
Simple
Pseudocyst
Parasitic
Retention
Primary Cystic Nonpancreatic
Neoplasms
Lesions
Adrenal cyst
Biloma
Choledochal
Choledochocele
Diverticulum
Duplication
Mesenteric
Retroperitoneal
Splenic artery
aneurysm
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Primary Pancreatic Cystic
Neoplasms
• Mucinous Tumors
– Cystadenoma
– Cystadenocarcinoma
– Intraductal papillary
mucinous tumor (IPMN)
• Acinar cell
cystadenocarcinoma
• Angiomatous tumor
– Angioma
– Hemangioma
– Lymphangioma
• Nonmucin Tumors
– Serous cystadenoma
– Solid-pseudopapillary
tumor
• Cystic degeneration
•
•
•
•
Islet cell tumors
Lymphoepithelial cyst
Pancreaticoblastoma
Teratoma
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Epidemiology
TYPE
GENDER
AGE
%
Serous cystadenoma
F>M
60s
32-39
Mucinous cystic neoplasm
F>M
40s
10-45
IPMN
M=F
50s
21-33
Solid pseudo-papillary
F>M
30s
<10
Cystic endocrine neoplasm
M=F
40s
<10
Ductal adenocarcinoma with
cystic degeneration
M>F
50s
<1
Acinar-cell
cystadenocarcinoma
M>F
50s
<1
Brugge WR. et al. N Engl J Med.351:1218-26.2004.
Serous Cystadenoma
• Microcystic, serous, or glycogen-rich
adenomas
• Presentation
– 50-60% have abdominal pain (up to 25 cm)
– 30% palpable mass
– Occ. obstructive jaundice, pancreatitis,
pancreatic insufficiency, or gastric outlet obst.
– 25% small & asymptomatic found on CT
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Serous Cystadenoma
• Focal, welldemarcated lesions
• Multiple (>6), small
(<1-2 cm), fluidfilled microcysts
• Dense fibrous
septations give
honeycomb
appearance
8 mm
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Serous Cystadenoma
Source: www.jichi.ac.jp
WHO Classification
Mucin-producing cystic neoplasms of the pancreas
Mucinous cystadenoma
Intraductal Papillary
Mucinous Neoplasm
(IPMN)
Mucinous cystadenocarcinoma
Mucinous Cystadenoma
• Macrocystic adenoma
• Premalignant
– 25% contain
malignancy at time of
diagnosis
• Presentation
–
–
–
–
Pain (60-80%)
Diabetes (25%)
Pancreatitis (10-20%)
Incidental (10-30%)
• Ovarian stroma
Grogan JR et al. AJR 176:921-9.2001.
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Ovarian Stroma
Intraductal Papillary Mucinous
Neoplasm (IPMN)
Main Duct Variant
Side Branch Variant
Grogan JR et al. AJR 176:921-9.2001.
IPMN
• Presentation
– Pain (50-100%)
– Acute pancreatitis (22-45%)
– Asymptomatic (up to 30%)
• Variants
– Main duct (47-75%)
– Side branch (25-39%)
– Both (14%)
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Evaluation of PCNs
• 10-37% initially diagnosed erroneously as
pseudocyst
– Delay in diagnosis
– Lost opportunity for curative resection
• Type of PCN
– Demographics
– Radiology
– EUS with FNA
Imaging of PCNs
SCA
MCN
IPMN
Even
Body/tail
Head
Septae
Yes
Yes
No
Locularity
Multi
Multi
Multi
Central
sunburst
Peripheral
curvilinear
None
PD displaced
PD displaced
PD dilated &
mucin
Location
TUS/CT/EUS
Calcifications
ERCP
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Serous Cystadenoma
CT Findings
Demos TC et al. AJR. 179:1375-1388.2002.
IPMN and ERCP
Aithal GP et al. Gastrointest Endosc.56(5):701-7.2002.
Pancreatic Duct
IPMN Histology
Pancreatic Cyst Fluid Analysis
Viscosity
Amylase
CA 19-9
CEA
Cytology
Serous
cystadenoma
Low
Variable
Variable
Low
Glycogen
Mucinous
cystadenoma
High
Variable
Variable
High
Mucin
Mucinous
cystadenoCA
High
Variable
Variable
High
Mucin
IPMN
High
High
Variable
Variable
Mucin
Pseudocyst
Low
High
Variable
Low
Histiocytes
Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.
Pancreatic Cyst Fluid Analysis
• 19 pancreatic cystic masses, 31 pseudocysts
• 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
Hammel P. et al. Gastroenterology.108:1230-5.1995.
Diagnosis of Pancreatic Cystic
Neoplasms
•
•
•
•
Multicenter trial
341 pts EUS-FNA
112 pts surgical resection
Prospective evaluation:
– EUS imaging,
– Cyst fluid cytology,
– Cyst fluid tumor markers
• CEA, CA 72-4, CA 125, CA 19-9, and CA 153
Brugge WR. et al. Gastroenterology.126:1330-6.2004.
Diagnosis of Pancreatic Cystic
Neoplasms
Accuracy
– CEA
• (88 of 111, 79%)
– EUS morphology
• (57 of 112, 51%)
– Cytology
• (64 of 109, 59%)
Brugge WR. et al. Gastroenterology.126:1330-6.2004.
Proposed Management
Algorithm for Symptomatic PCNs
Scheiman JM. Gastroenterology.128:463-9.2005.
Proposed Management Algorithm
for Asymptomatic PCNs
Castillo, C. F.-d. et al. Arch Surg.138:427-34.2003.
Pancreatic Cystic Neoplasm
EUS Guided Cyst Aspiration
Amylase
CEA
CA 19-9
93
906
1,890,000
Pancreatic Cystic Neoplasm
Pancreatic Cyst
Amylase 502
CEA 2.5
CA 19-9 ----
Case Presentation