Diagnosis And Management Of Pancreatic Cystic Lesion

Brief reviewBrief review

Diagnosis and management of pancreatic cystic lesion

Myoung Hwan Kim

Department of Internal Medicine,

Division of Gastroenterology

Although the clinical, radiologic, and pathologic features of cystic pancreatic lesions are well known, preoperative diagnosis is difficult.

Differentiation between a pancreatic pseudocyst and a cystic pancreatic neoplasm is crucial in determining the proper treatment.

Recently, wide application of CT and ultrasound in asymptomatic and mildly symptomatic patients has increased detection of incidental cystic lesions of the pancreas

differential diagnosis of pancreatic cystic lesions has become more challenging

pancreatic cystic lesion

Incidental pseudocyst 77/F Serous cystadenoma 77/M Mucinous cystadenoma 38/F

Pseudocysts are the most common cystic lesions of the pancreas(70-90%).

All other cystic lesions including cystic neoplasms represent only 10%–15% of pancreatic cysts.

Differentiating pancreatic pseudocysts from nonpseudocysts is important for determining treatment.

1. Pancratic psedocyst

3wks after conservative Tx More 3weeks PCD 2 month later

1. Pancratic psedocyst Most cystic masses of the pancreas encountered in clinical

practice are postinflammatory pseudocysts.

Pancreatic pseudocysts are defined as localized amylase-rich

fluid collections located within the pancreatic tissue or

adjacent to the pancreas and surrounded by a fibrous wall that

does not possess an epithelial lining The CT finding a round or oval fluid collection with a thin, barely

perceptible wall or thick wall that shows evidence of contrast

enhancement

They develop most often as a complication of acute or chronic

pancreatitis and may develop secondary to pancreatic trauma

or surgery

1. Pancratic psedocyst Although a prior history of pancreatitis cannot by itself justify

the diagnosis of pancreatic pseudocyst, careful evaluation of

the patient’s clinical history is important for the accurate

diagnosis of pseudocyst.

Clinical scenarios Clinical scenarios a pseudocyst developing after identifiable acute pancreatitis a pseudocyst developing after identifiable acute pancreatitis

a pseudocyst resulting from an acute incident superimposed on chronic a pseudocyst resulting from an acute incident superimposed on chronic

pancreatitispancreatitis

a pseudocyst with an uncertain or no known previous clinical history a pseudocyst with an uncertain or no known previous clinical history

of pancreatitisof pancreatitis

1. Pancratic psedocyst Classic Postinflammatory Pancreatic Pseudocyst

Pancreatic Pseudocyst Superimposed on Chronic Pancreatitis Pancreatic Pseudocyst Superimposed on Chronic Pancreatitis Pancreatic pseudocysts can occur in association with chronic Pancreatic pseudocysts can occur in association with chronic

pancreatitis as chronic pseudocysts pancreatitis as chronic pseudocysts a distinct clinical history of a distinct clinical history of

acute pancreatitis may be lacking and the pseudocyst is often detected acute pancreatitis may be lacking and the pseudocyst is often detected

incidentallyincidentally

The recognition of a pancreatic pseudocyst resulting from chronic The recognition of a pancreatic pseudocyst resulting from chronic

pancreatitis is usually easy when there are associated pancreatitis is usually easy when there are associated stigmata of stigmata of

chronic pancreatitischronic pancreatitis such as parenchymal calcifications or ductal such as parenchymal calcifications or ductal

stones, stones, ductal dilatation, and atrophy of the parenchymaductal dilatation, and atrophy of the parenchyma

However, without these findings, pseudocysts will be very difficult to However, without these findings, pseudocysts will be very difficult to

distinguish from distinguish from IPMTIPMT..

1. Pancratic psedocyst Pancreatic Pseudocyst without an Antecedent Episode of

Acute Pancreatitis Detection of incidental pancreatic cysts in an asymptomatic patient

poses a diagnostic problem. Incidental pancreatic cysts are smaller than symptomatic cysts and are

unlikely to be pseudocysts Cystic pancreatic neoplasm should be considered in the differential

diagnosis of a pancreatic cyst, even in patients with a history of pancreatitis, if no recent episode of acute pancreatitis can be documented on clinical or imaging grounds.

For pancreatic pseudocysts without an antecedent episode of acute pancreatitis and radiologic evidence of pancreatitis, US-, CT-, or EUS–guided aspiration or biopsy or at least a follow-up study should be recommended.

Regardless of size, an asymptomatic pseudocyst does not require treatment.

Abdominal ultrasonography every 3 to 6 months.

ERCP is usually done before attempting drainage

1) Surgical drainage of a pseudocyst

cyst-gastrostomy, cyst-duodenostomy, Roux-en-Y cyst-jejunostomy, pancreatic resection if the pseudocyst is in the tail.

2) Percutaneous catheter drainage

3) Endoscopic methods

transmural - endoscopic cyst-gastrostomy or cyst-duodenostomy,

transpapillary - via the p-duct and into the pseudocyst

Treatment of pancratic psedocyst in acute pancreatitis

25% of patients with chronic pancreatitis

Persistent elevation in serum amylase

Size of the pseudocyst (6 cm) – the most important predictor of the need for intervention

Symptomatic, complicated, or enlarging pseudocysts - percutaneous, endoscopic, or surgical therapy

Treatment of pancratic psedocyst in chronic pancreatitis

ERCP–based algorithm for management ERCP–based algorithm for management of pancreatic pseudocystsof pancreatic pseudocysts

Cystic pancreatic neoplasms are uncommon but important because they are increasingly being detected.

Cystic pancreatic neoplasms are generally associated with symptoms, but an increasing number of incidental pancreatic cysts are being found.

Definitive diagnosis is often possible when the lesions show typical radiologic appearances, but in many cases diagnosis by imaging alone is impossible.

2. Pancratic cystic neoplasm

Mucinous cystadenoma 67/F Branch duct IPMN Serous cystadenoma 77/M

Differential diagnosis Differential diagnosis pseudocyst vs cystic neoplasmpseudocyst vs cystic neoplasm

Diagnosis of cystic neoplasm (1)Diagnosis of cystic neoplasm (1)

< Brugge WR et al. N Engl J Med 2004;351:1218-26>



< Scheiman JM. Gastroenterology 2005;128:463-9 >



Tumor markers:

may useful in confirming the diagnosis and possibly identifying malignant change

Algorithmic approach for the management of Algorithmic approach for the management of cystic pancreatic lesions based on cystic pancreatic lesions based on

the morphologic features of the lesionthe morphologic features of the lesion

< Sahani DV et al. Radiographics 2005;25:1471-84>

Algorithmic approach for the management of Algorithmic approach for the management of cystic pancreatic lesions based on cystic pancreatic lesions based on

the morphologic features of the lesionthe morphologic features of the lesion

< Sahani DV et al. Radiographics 2005;25:1471-84>

Mucinous Cystic NeoplasmMisdiagnosed as a Pseudocyst

52-year-old woman with epigastric pain.52-year-old woman with epigastric pain.

Despite the absence of a history of Despite the absence of a history of

pancreatitis, the thin cyst wall led to pancreatitis, the thin cyst wall led to the the

presumptive diagnosis of a pseudocyst. presumptive diagnosis of a pseudocyst.

CT scan shows a thin-walled cyst in the CT scan shows a thin-walled cyst in the

pancreatic tail. There is a tiny peripheral pancreatic tail. There is a tiny peripheral

intramural nodular structure (arrow), intramural nodular structure (arrow),

which was initially overlooked.which was initially overlooked.

At surgery, the lesion proved to be a At surgery, the lesion proved to be a

mucinous cystadenocarcinoma.mucinous cystadenocarcinoma.

Approach to Approach to Incidental pancreatic cystIncidental pancreatic cyst

< Castillo CF et al. Arch Surg 2003;138(4):427-3>

< Castillo CF et al. Arch Surg 2003;138(4):427-3>

Approach to Approach to Incidental pancreatic cystIncidental pancreatic cyst

management approach for management approach for pancreatic cystic lesion.pancreatic cystic lesion.

< Scheiman JM. Gastroenterology 2005;128:463-9 >

SummaryPatient with pancreatic cystic lesion

Associated with acute or chronic pancreatitis ?

PseudocystNon-pseudocyst

IPMN or mucinous cystadenoma

Size>5cm, symptom (+)

surgeryWait & See

YesNo YesNo

Yes

No

unilocular microcyst /c solidmacrocyst

Wait & See

Yes

Serous cystadenoma

Cyst aspiraton (PC, ERCP) or surgery

Size>2cm, Symptom (+), yonge age

Yes

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Diagnosis And Management Of Pancreatic Cystic Lesion