CYSTIC PANCREATIC

LESIONS
R3 PANISARA
EPIDEMOLOGY
Incidence : 1.2 - 2.6 % on
CT, and 2.4 - 49.1 % on MRI
Population-based incidences
of pancreatic cyst are
reported to be 2.6 % in
Germany and 2.2 % in
Korea, and the incidence
increases with age

CHANG ET. AL. MEDICINE, 2016, 95 (51),.

CLASSIFICATION
Non neoplastic cysts -Pseudocyst
• Neoplastic cyst
Serous
SCA:Serouscystadenoma
Mucinous
MCN:mucinouscysticneoplasm
IPMN:Intraductalpapillarymucinousneoplasm
Solid tumor-Cystic degeneration
SPEN:Solid pseudopapillary epithelial
neoplasm
PNET(cystic):Pancreatic neuroendocrinetumor
CLASSIFICATION
 Goal: Differentiate Mucinous
from Non-mucinous cysts

Increasing Malignant Risk

 CT: Cystic neoplasm imaging

Detection of cystic lesion

Characterization of cyst
Location
Internal architecture
Enhancement
Ca++ etc
 MRI/MRCP

Detailed characterization
Communication with the pancreatic
duct
Extent of MPD involvement
Mural nodules etc
 Role of EUS
Evaluation of internal architecture-
septations, mural nodules, solid
areas, vascular invasion, LAP etc
Cyst fluid aspiration
Biopsy of suspicious areas
Less risk of spillage of cyst contents
PRESENTATION, PATIENT AGE, GENDER AND LOCATION OF THE
CYSTIC LESION ARE VERY IMPORTANT WHEN COMING UP WITH A
DIFFERENTIAL DIAGNOSIS*
PSEUDOCYSTS
 Pseudocysts
Represent up to 85% of cystic
lesions, localized loculated
Key clinical history:
Alcohol use
Pancreatitis
In absence of such a history,
mucinous cystic neoplasm must
be considered in the differential
 Pseudocysts

OHTSUKA ET. AL. PANCREATOLOGY. 2023 DEC 28:S1424

 SEROUS CYSTIC
NEOPLASM (SCN)

GRANDMOTHER LESION
 Serous cystic neoplasm (SCN)

Serous cystic neoplasm (SCN)

microcystic, macrocystic,
oligocystic
"honeycomb" appearance
female predominance(75%),
60-70 years
body/tail > head
Essentially no malignant
potential (25 reported cases)
Resect for symptoms
 Serous cystic neoplasm (SCN)

MICROCYSTIC LESION
Multiple locules > 6,
Locule size < 2cm
Hypervascular fibrovascular core
Sharp interface with vessels
Rarely obstructs - bile duct, panc duct
CROSS-SECTIONAL
IMAGING: SCN
Serous cystic neoplasm (SCN)

OHTSUKA ET. AL. PANCREATOLOGY. 2023 DEC 28:S1424

MUCINOUS CYSTIC
NEOPLASM (MCN)

MOTHER LESION
 Mucinous cystic neoplasm (MCN)

unilocular, oligocystic
Ovarian stoma
female predominance, 40-60 years
body/tail > head
Prevalence of malignancy ~ 15%
Malignant potential over time
 Mucinous cystic neoplasm (MCN)
unilocular, oligocystic
Mucinous cystic neoplasm (MCN)

OHTSUKA ET. AL. PANCREATOLOGY. 2023 DEC 28:S1424

IPMN
 IPMN
Dilation of main duct, branch duct or both
M/F ratio roughly equal, 60-70 years
head > body/tail
 IPMN
Main Duct - prevalence of malignancy as high as 40%
Always consider surgical referral
Branch Duct - lower prevalence of malignancy ~10-25%
May be multifocal
Variable treatment strategy
Mixed Type - main duct + branch duct
Treat as Main Duct Type
 MD-IPMN

IMAGING FINDINGS
Main PD dilatation
BULGING & fish mouth appearance of the ampulla
Accumulation of mucin/tumor leads to ductal strictures
and chronic pancreatitis.
Atrophic changes can be present in the pancreatic
parenchyma
CROSS-SECTIONAL IMAGING:
MAIN DUCT IPMN
 BD-IPMN

IMAGING FINDINGS
Can involve the head body or the
tail-bunch of grapes appearance
MRCP important to establish ductal
communication
Lesions < 3cm
have a lower risk of malignancy
CROSS-SECTIONAL IMAGING:
BRANCH DUCT IPMN
 CROSS-SECTIONAL IMAGING:
MULTIFOCAL BRANCH DUCT IPMN
 BD-IPMN

OHTSUKA ET. AL. PANCREATOLOGY. 2023 DEC 28:S1424

 SOLID
PSEUDOPAPILLARY
NEOPLASM (SPN)

Daughter lesion
Solid Pseudopapillary Neoplasm (SPN)

Low grade malignant neoplasm

Young women (<35 years)
monomorphic cells (often difficult to distinguish from
neuroendocrine), pseudopapillae
hemorrhagic areas
Surgical resection
Solid Pseudopapillary Neoplasm (SPN)

Large masses, encapsulated

Cystic and hemorrhagic areas
Ca+ peripheral
MPD dilation uncommon
WHAT IS THE ROLE OF
EUS?
EUS Imaging can:
Identify intracystic mucin, nodules
Determine relationships to vasculature,
main duct, resectability
Provide high resolution imaging of the
parenchyma
EUS imaging alone is often inadequate to
distinguish cyst types and malignant risk
WHEN IS EUS REFERRAL NOT
NECESSARY?
Cyst size < 1 cm
Cyst arising in setting of acute pancreatitis
(*cystgastrostomy)
Elderly, poor surgical candidate
Classic CT/MRI findings
Large hemorrhagic cyst in young woman
Microcystic lesion in tail with central scar
 EUS-FNA

Cyst Fluid Analysis (CFA):

Cytology - low yield, sensitivity 40-60%
Chemical Analysis
СЕА
Amylase
kras mutation, DNA analysis - promising but still
investigational
Safe:
Pancreatitis 1-3.5%
Bleeding 1.5-6%
Fever 0.6%
 EUS-FNA: Cyst Fluid Analysis

BRUGGE WET AL. GASTROENTEROLOGY, 2004 MAY; 126(5): 133

 EUS-FNA: Cyst Fluid Analysis

BRUGGE WET AL. GASTROENTEROLOGY, 2004 MAY; 126(5): 133

EUS-FNA: Cyst Fluid Analysis
 Meta-Analysis of Cyst Fluid Glucose Levels

Cyst fluid glucose level < 50 compared to CEA > 192

No benefit to CEA + glucose to glucose alone

MCCARTY TR, ET AL. GASTROINTEST ENDOSC. 2021 OCT;94(4): 698-712.6.

 CURRENT
GUIDELINES
THE DILEMMA REGARDING
PANCREATIC CYSTS

Unnecessary Resections
Vs.
Missed Cancers
 GUIDELINES
Sendai (2006), Fukuoka (2012), Revised Fukuoka (2017)
European Experts Consensus Statement - 2013
AGA 2015
ASGE (regarding endoscopic role) - 2016
ACG 2018
European Guidelines 2018 (Gut
Kyoto guidelines 2023
WHAT ARE WE
LOOKING FOR?
SUSPECTED
BD-IPMN
The Past - Fukoka Guidelines 2017
WHAT ARE WE
LOOKING FOR?
Kyoto guidelines 2023
Kyoto guidelines 2023
Kyoto guidelines 2023
Surgery
Whipple Resection Distal Pancreatectomy
(Head, uncinate, (Some neck cysts, body, tail
some neck cysts) cysts)
 TAKE-HOME POINTS
Cysts are common, increasingly diagnosed on cross-sectional
imaging tests
Key is to distinguish mucinous versus non-mucinous
Clinical and imaging characteristics often unreliable
EUS-FNA with cyst fluid analysis can assist in cyst
characterization, but is still quite imprecise
Diagnostic and treatment algorithms are evolving as new
technology and increasing data become available
Novel EUS-guided imaging and tissue sampling modalities may
allow for more definitive diagnoses of cystic neoplasms, avoiding
further surveillance for benign cysts