(Neo)-Adjuvante Prinzipien beim Pankreas-Karzinom

Pancreatic Cystic Neoplasms

Bible Class4th Sept.2013

Universitätsklinik für Viszerale Chirurgie und Medizin

Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch

What type of pancreatic cysts exist ?

Acquired Cysts:

Congenital Cysts:

Cystic Neoplasms:

Post-inflammatory fluid collectionPseudo-,-PseudocystPostnecrotic sequestrumParasitic, Ecchinococcal etc.

True cystsEnterogenous cysts/ duplication cysts(Epi)dermoid cysts, EndometriosePolycystic diseases; Cystic Fibrosis

Cystic Neoplasms:- IPMN: Intraductal papillary mucinous neoplasm- MCN: Mucinous cystic neoplasm- SCN: Serous cystic adenoma/ neoplasm- SPN: Solid pseudopapillary neoplasm- CPEN: Cystic pancreatic endocrine neoplasm

Why is this differentiation important ?

Risk Malignancy

Benign


How frequent are neoplastic pancreatic cystic lesions ?

Average: 2.5%

Age > 70 years: 10-20%*

*: MRI in non-pancreatic disease: 20% of 1444 patients; Zhang XM et al. Radiology 2002


Key features: Serous Cystic Neoplasm

Malignant potential: Location: Demographics, rate: Morphology: micro-, oligo-, macrocystic

typically: multicystic cluster (each < 2 cm) = honeycumbed

No communication with pancreatic duct

Stroma: (central fibrous and) calcified (stellate scar)

NO

throughout the pancreas (older) women (80%), 15-20% of PCNs


Key features: IPMN

Types: Malignant potential: Location: Demographics, rate: Morphology:

Yes (esp. main/combined duct IPMN)

M: head BD: multifocal !!

Equal m/w, middle-age/old; >25% of PCNs

Main-, branch-duct, mixed type

Cystic dilatation main (> 6 mm) or side

branches; M: Fish-mouth, globules of mucin (= masses)

Stroma: Lack of ovarian stroma (vs. MCN)


Key features: MCN

Malignant potential: Location: Demographics, rate: Morphology:

Yes (but lower than IPMN)

Body/tail (95%), always single lesion!Middle-aged women (95%), 25% of PCNs

thick-walled single cyst, often septations

Epithelial layer with mucin-producing cells, ovarian-like stroma

No communication with pancreatic duct


Risk of malignancy in pancreatic neoplastic cysts ?

IPMN: BD-:

MD-:

MCN:

SCN:

SPN:

CPEN:

1: Sakorafas GH et al. Surg Oncol. 2011; 2 Sakorafas GH et al. Surg Oncol 2012

++ ̴ 40% (6-46%) Risk of HGD/ malignancy 1

++++ ̴ 65% (57-92%) Risk of HGD/ malignancy in 5 y 1

++ 6-36% Prevalence malignancy 1

(+) VERY low (malignant = serous cystadenocarcinoma)

+ Low malignant potential 2

Variable 2

What factors determine malignant risk in IPMN/MCN?

Size

Histopathological type


What are high-risk stigmata for malignancy in IPMN/MCN?

Obstructive jaundice (and cystic lesion of the pa-head)

Enhancing solid component within cyst

Main pancreatic duct > 10 mm in size

Consequence?

Consider surgery, if clinically appropriate


If no high-risk stigmata in IPMN/MCN:What are worrisome features ?

Clinical: PancreatitisImaging: Cyst > 3 cm

Thickened/enhancing cyst wallsMain duct size 5-9 mmNon-enhancing mural noduleAbrupt change in caliber of pancreatic ductwith distal pancreatic atrophy

Consequence?

Endo-Sonography


What are the advantages of EUS in diagnostic workup of pancreatic cysts ?

Superior, higher-resolution imaging of the pancreas

(ductal communication, additional (smaller) cysts, nodules etc.)

Fine-needle-aspiration (FNA): sampling fluid for

Cytology and tumor markers



Operator-Dependent Investigation Sampling Error Contamination (gastric wall) Low cellularity -> Low senstivity

e.g. SCN only 30-40% enough cells

diagnostic accuracy: 10-60%

often NON-diagnostic

What are drawbacks of EUS ?

Including high-grade

atypical epithelial cells:

diagnostic in mucinous cysts

diagnostic accuracy: 80%


What are EUS features leading to consider surgery ?

Define mural nodule(s): 3-9 fold risk malignancy Main duct features suspicious for involvement Cytology: suspicious or positive for malignancy


EUS-FNA: Fluid Analysis in Cysts

Typ SCN MCN IPMN SPN Pseudocyst

Viscosity

Mucin

Amylase

CytologyCytology negative or

Glyogen-con-taining cuboid

cells

mucin-

containing column cells

papillary clusters ofmucin-

column cells, atypia

Branching papillae

cuboid or cylindric cells, high cellularity, myxoid stroma

«dirty material»

Macrophages,Inflammatory cell

Viscosity Low High High NA Low

Mucin Low High High NA Low

Amylase < 250 U/L < 250 U/L < 250 U/La Low High


CEA in Cyst-Fluid: What for ? Useful ?

Mucinous vs. Non-mucinous (serous)

Cut-off unclear: e.g. > 800 ng/mL

No correlation with risk of malignancy


How to perform surveillance for BD-IPMN and MCN?

< 1 cm:

1-2 cm:

2-3 cm:

> 3 cm:

CT/MRI in 2-3 years

Close surveillancealternating MRI with EUS every 3-6 monthsStrongly consider surgery (in young, fit patients)

EUS in 3-6 monthsLengthen interval, alternating EUS and MRIConsider surgery in young, fit patients (long surveillance)

CT/MRI yearly (for 2 years) lengthen interval if no change


Which syndrome associates with multiple/oligocystic SCN ?

Hippel-Lindau-Syndrome

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(Neo)-Adjuvante Prinzipien beim Pankreas-Karzinom