5/17/2013 Pancreas Cysts Overview Common Work-up often - PowerPoint PPT Presentation

5/17/2013 Pancreas Cysts Overview • Common • Work-up often nondiagnostic Postgraduate Course in General Surgery • Possibly benign, premalignant, malignant • Pancreas cancer difficult to cure Pancreas Cysts • Real consequences of under-/over-treatment Eric K. Nakakura San Francisco, CA May 17, 2013 Pancreas Cysts Pancreas Cysts Prevalence of unsuspected cysts Differential diagnosis • 2.6% (73/2832) overall • Benign – Pseudocyst • 8.7% in 80 - 89 year-olds – Serous cystic neoplasm (SCN) – Simple cyst, retention cyst, congential, lymphoepithelial cyst • Size: 2 - 38 mm (mean, 8.9 mm) • Potentially malignant – Solid pseudopapillary neoplasm (SPN) • More common in Asians (odds ratio = 3.57) – Intraductal papillary mucinous neoplasm (IPMN) – Mucinous cystic neoplasm (MCN) – Neuroendocrine tumor • Malignant – Ductal adenocarcinoma Laffan et al. AJR 2008 1

5/17/2013 Pancreas Cysts Pancreas Cysts Suboptimal preoperative diagnosis Pathological diagnosis (n = 212) Intraductal papillary 75 (35%) • mucinous neoplasm (IPMN) Mucinous cystic 43 (19%) • neoplasm (MCN) Serous cystadenoma 23 (11%) • Pseudocyst 29 (14%) • Ductal adenocarcinoma 14 (7%) • 1/3 had incorrect preoperative diagnosis • Other 28 (13%) 5% not neoplastic • • Correa-Gallego et al. Pancreatology 2010 Fernandez-del Castillo et al. Arch Surg 2003 Pancreas Cysts Pancreas Cysts Precursors to pancreas cancer Precursors to pancreas cancer • Pancreatic epithelial neoplasia • Pancreatic epithelial neoplasia Too small to see • Intraductal papillary mucinous neoplasia • Intraductal papillary mucinous neoplasia Cystic • Mucinous cystic neoplasms • Mucinous cystic neoplasms 2

5/17/2013 Pancreas Cysts Pancreas Cysts Precursors to pancreas cancer What should be done if a pancreas cyst is seen? • Pancreatic epithelial neoplasia Too small to see • Ignore it? • Intraductal papillary mucinous neoplasia • Follow it? Cystic • Mucinous cystic neoplasms • Resect it? • Asymptomatic pancreas cyst might be a treatable precursor to pancreas cancer Pancreas Cysts Pancreas Cysts Factors to consider Neoplastic cysts • Size • Serous cystic neoplasm (SCN) • Solid pseudopapillary neoplasm (SPN) • Imaging characteristics • Mucinous cystic neoplasm (MCN) • Intraductal papillary mucinous neoplasm (IPMN) • Clinical factors • Endoscopic ultrasound (EUS)/ Fine needle aspiration (FNA) 3

5/17/2013 Pancreas Cysts Pancreas Cysts Neoplastic cysts • Nonmucinous • Serous cystic neoplasm (SCN) • Solid pseudopapillary neoplasm (SPN) Mucinous • • Mucinous cystic neoplasm (MCN) • Intraductal papillary mucinous neoplasm (IPMN) Dixon et al. WJGS 2013 Pancreas Cysts Pancreas Cysts IPMN: Main- more aggressive than branch-duct • Main duct • Branch duct Jani et al. Diagn Ther Endosc 2011 Tanaka et al. Pancreatology 2006 4

5/17/2013 Pancreas Cysts Pancreas Cysts Management of IPMNs Natural history of branch duct IPMN • Main duct – Most patients should undergo resection • Branch duct – Sendai (Tanaka) Criteria for resection • Size > 3 cm moderate • Symptoms strong • Mural nodule strong Tanaka et al. Pancreatology 2006 Maguchi et al. Pancreatology 2012 Pancreas Cysts Pancreas Cysts Case 1: Case 1: • 74-year-old man – Weight loss (30 pounds) over 5 months and 3-4 loose, floating stools/day 5

5/17/2013 Pancreas Cysts Pancreas Cysts Case 1: Main duct IPMN • What is the diagnosis and treatment? SMV SMA Pancreas Cysts Pancreas Cysts Main duct IPMN Main duct IPMN • Pathology – Mixed main duct/branched duct IPMN (8.5 cm) with an invasive colloid carcinoma (< 0.5 cm) – Margins negative – pT1N0 (0/52 LNs) 6

5/17/2013 Pancreas Cysts Pancreas Cysts Case 2: Case 2: • 58-year-old woman – Early satiety, weight loss, loose stools, new onset diabetes Pancreas Cysts Pancreas Cysts Case 2: Serous cystic neoplasm • What is the diagnosis and treatment? 7

5/17/2013 Pancreas Cysts Pancreas Cysts Case 3: Case 3: • 20-year-old woman – Intermittent epigastric pain over 4 years Pancreas Cysts Pancreas Cysts Case 3: Solid pseudopapillary neoplasm • What is the diagnosis and treatment? 8

5/17/2013 Pancreas Cysts Pancreas Cysts Treatment algorithm Conclusions • Common: You will see it! • Work-up often nondiagnostic • Possibly benign, premalignant, malignant • Pancreas cancer difficult to cure • Real consequences of under-/over-treatment • Complex decisions: work-up and management Jani et al. Diagn Ther Endosc 2011 Pancreas Cysts Conclusions • Consider resection for: – SCN: > 4cm, symptomatic – SPN: 10-15% risk of metastases – Any MCN – Any main duct IPMN – Branch duct IPMN: > 3cm, symptomatic, nodule 9

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