1. Dr. Ketul V. Shah
1st year MCh G.I.Surgery resident
V.S. Hospital, Ahmedabad
Discussion; Dr Sanjay Nagral,
Consultant GI surgeon,Mumbai.

2. Cystic lesion in Pancreas
Task ahead
I. Is the lesion from pancreas?
II. Lesion is solid or cystic?
III. Neoplastic v/s non-neoplastic?
IV. SCA v/s MCN v/s IPMN?
V. Management?

3. CASE HISTORY
 45y/F
 c/o recurrent vomiting and loss of appetite - 6 mths.
 Vomitus contained food and occurred ½ to 1 hour after
meals & was non-bilious, non-projectile
 h/o diffuse abdominal pain
 significant weight loss ++
 Anorexia ++

4.  There was no preceding history of any severe
abdominal pain or jaundice
 No h/o lump in abdomen, abdominal distension
 Pt is not a k/c/o diabetes and no other positive medical
or surgical history

5. ON EXAMINATION
 pallor +, No LNpathy
 P/A- soft, non tender, no palpable lump, no
organomegaly. No ascitis.
 other systems normal.

6. INVESTIGATIONS DONE
 LFT – wnl
 S. Amylase and Lipase were normal
 USG - A cystic lesion in the pancreatic head and
neck region of about 7x5cm
 CECT - 73x60 mm cystic lesion in pancreatic head
& neck region; cystic wall-3mm; MPD- normal; no
peri-pancreatic LN or fluid.
 S. CA 19-9 – wnl
 S. CEA - wnl

8. While approaching a cystic lesions
we need to know….
 Broad differential diagnosis
 Epidemiology of common lesions
 Clinical presentation
 Blood tests
 Imaging
 Histology

9. Broad D/D’s of Cystic Pancreatic
Lesions
1) Pseudocyst (75-80%)
2) Common cystic pancreatic neoplasms
 Mucinous cystic neoplasm (10-45%)
 Serous cystic neoplasm (32-39%)
 IPMN (21-33%)
3) Rare cystic pancreatic neoplasms
 Solid pseudopapillary tumor (<10%)
 Acinar cell cystadenocarcinoma (<!%)
 Lymphangioma
 Hemangioma
 Paraganglioma

10. 4) Solid pancreatic lesions with cystic degeneration
 Pancreatic adenocarcinoma (<1%)
 Cystic islet cell tumor
(insulinoma, glucagonoma, gastrinoma) (<10%)
 Metastasis
 Cystic teratoma
 Sarcoma
5) Hydatid cyst
6) Lymphatic cyst
7) True epithelial cysts a/w-
 von Hippel–Lindau disease
 autosomal -dominant polycystic kidney disease

11. Imaging in Cystic lesions….
 As against Solid lesions, Imaging may be
diagnostic in many cystic lesions, obviating further
investigations

12. Imaging in cystic lesions of
pancreas;
How does it help???

13. Four Morphologic Types of Cystic
Lesions of the Pancreas

14. a) Unilocular Cyst
 Pseudocyst- most common
Other causes-
 IPMN occasionally
 Unilocular serous cystadenoma
 Lymphoepithelial cyst
 Multiple
 von Hippel-Lindau
 Pseudocysts

15. b) Microcystic Lesions
 Serous cystadenoma
(Only lesion included in this category)

16. c) Macrocystic Lesions
 Mucinous cystic neoplasms
 Intraductal Papillary Mucinous Neoplasm (IPMN)

17. d) Cysts with a solid component
- Unilocular or multilocular
 True cystic tumors or solid pancreatic neoplasms with
cystic component/degeneration
 Solid pseudopapillary tumor (SPEN)
 Mucinous cystic neoplasms
 IPMNs
 Islet cell tumor
 Adenocarcinoma
 Metastasis

18. Let us look at the possibilities in
our patient……

19. Could this patient have
PANCREATIC PSEUDOCYST?
 Symptoms
 Abdominal pain (80 – 90%)
 Lump in abdomen
 Nausea / vomiting ( due to gastric or duodenal compression)
 Early satiety
 Bloating, indigestion
 Jaundice ( due to compression of bile duct)
 Hemorrhage
 Signs
 Tenderness
 Abdominal fullness
 Palpable mass

20. Blood tests in suspected
pseudocyst
 Amylase/Lipase

21. Imaging in Pseudocyst…..
 Ultrasonography
 Most practical & Sensitivity 75 – 90%
 limited by patient habitus, operator experience and air in stomach
 CT scan
 Gold standard for initial assessment and follow-up
 Sensitivity  90- 100%
 MRI
 Better detail of content of cyst
 MRCP
 Establish the relationship of the pseudocyst to the pancreatic ducts
 Endoscopic Ultrasonography (EUS +/- FNA)
 Distinguishing pancreatic cystic lesions, helps in FNA

22. So, if you have a cystic lesions
with…..
 Sudden onset of pain consistent with pancreatitis pain
 Imaging features of associated pancreatitis
 Unilocular cyst; and
 Elevated amylase/lipase
You may not investigate any further…… It must be
a pseudocyst

23. Common neoplastic lesions
and their features….

24. Cystic neoplasm of pancreas

25. MUCINOUS CYSTIC NEOPLASMS
 Most common - 10% to 45% (MCA -67%, MCAC -
33%)
 > 95% in women ( Mean ~ 50 yrs)
 Typically involve the body and tail of the pancreas
 Never multifocal, occurring only in one location
within the pancreas.

26.  Asymptomatic in 75% cases
 If symptoms, usually due to mass effect
 Adominal pain
 Palpable mass

27.  CT or MRI of the abdomen
 Complex macrocystic mass with internal septations
 MRCP no communication between duct and the cyst
 Contrast enhanced scans show enhancement of the cyst wall and
accentuate any septations and mural nodules
 Distal to the tumor, the pancreas may show changes of CP
 Presence of mural nodule and septal calcification s/o –
malignancy

28.  EUS can identify septations and cyst wall nodules in
more detail than MRI or CT
 Allows cyst wall biopsy and cyst fluid aspiration for
analysis
 Cyst fluid analysis generally reveals
 thick and mucoid material and low fluid amylase
 elevated tumor markers (CEA)
 mucinous epithelial cells by cytology

29. Mucinous Cystadenocarcinoma
 Complex macrocystic lesion with internal septations
 Peripheral and septal calcification indicative of malignancy
(arrowheads)

30. SEROUS CYSTADENOMAS
 Second MC Cystic tumor of the pancreas
 formerly known as microcystic adenomas
 Occurring mostly in women (75%) with a mean 62 years
 Most (50% to 70%) occur in the body or tail of the
pancreas
 An association with von Hippel-Lindau disease

31.  Mostly asymptomatic
 being detected during evaluation for other unrelated conditions
 Can present with a palpable mass - size (10 to 25 cm)

32. Serous Cystadenoma
Lesion with numerous
microcysts giving a
“honey-comb”
appearance
Lobulated outline
Central stellate scar

33. Serous cystadenoma
 Pathognomonic image by CT scan is that of a spongy mass
with a central “sunburst” calcification - only 10% of patients
 Visualization of four of the following five CT and MRI features
aid in making the diagnosis
 location in the pancreatic body and tail
 wall thickness < 2 mm
 lobulated contour
 lack of communication with the pancreatic duct
 minimal wall enhancement

34. IPMN
(Intra-ductal Papillary Mucinous Neoplasm)
 Types - depend on involvement of duct
 main pancreatic duct, isolated side branches, or a combination of
both
 Benign (adenoma), borderline, or malignant
 Malignant neoplasms account for 60% of IPMNs

35. IPMN FEATURES
 Equal frequency in men and women
 Median age at diagnosis - about 65 years
 75% of patients are symptomatic
 Abdominal pain and weight loss – MC complaints
 Recurrent pancreatitis or
 Acute pancreatitis
 Patients with malignant neoplasms are more likely to be
 older and more likely to present with jaundice or new-onset
diabetes

36. DIAGNOSIS
 Differentiation of IPMN from other cystic pancreatic
masses may be difficult at CT
 Most reliable findings for the diagnosis
 Presence of a communication between the cystic lesion and the
main pancreatic duct
 Presence of mural nodules projecting into the main
pancreatic duct or cystic lesions

37. DIAGNOSIS
 Diffusely distended pancreatic duct with mucinous filling
defects and grape-like, cystic, space-occupying lesions
 Sensitivity in diagnosing an IPMN
 highest for MRI with MRCP (88%),followed by ERCP (68%) and
CT (42%)

38.  Pathognomonic for IPMN in ERCP
 A wide and gaping papilla with secretion of mucin and filling
defects in the dilated pancreatic duct –FISH MOUTH AMPULLA

39. Cystic lesions of pancreas;
will blood tests help ?
 Amylase and/or Lipase??
 CEA? Ca 19-9 ??
Not diagnostic of any of the cystic pancreatic tumors
Only provide corroborative evidence

40. Serum amylase or lipase levels
Increased - pseudocyst, IPMN
Serum CA 19-9 & CEA
normal - benign cystic pancreatic tumors
modestly elevated - MCNs and IPMNs,
particularly patients with malignancies
Markedly elevated -retention cyst secondary
to obstruction of the main pancreatic
duct by an adenocarcinoma.

41. Cystic lesions of Pancreas; will
aspiration and analysis of fluid
help?

42. Cyst Fluid Analysis
Viscosity Amylase Cytology
Pseudocyst Low High Inflamm.
SCA Low Low 5% +
MCA High Low 40% +
MCAC High Low 67% +
CEA CA 15-3 CA 72-4
Pseudocyst Low Low Low
SCA Low Low Low
MCA High High Low
MCAC High High High
[1] Lewandrowski KB, et al. Ann Surg 1993, 217:41-7.
[2] Brugge WR, et al. N Engl J Med 2004, 351:1218-26.

43. Coming back to our case…

44. Our patient has….
 No clear cut diagnosis on history
 Serum markers were non-informative
 Imaging not diagnostic
 Therefore EUS guided FNA was
done..……Adenocarcinoma with cystic degeneration

45. DR. KETUL SHAH