Cystic Pancreatic Lesions: Approach to Diagnosis

Transcription

1 Cystic Pancreatic Lesions: Approach to Diagnosis Poster No.: R-0130 Congress: RANZCR-AOCR 2012 Type: Educational Exhibit Authors: A. AGARWAL, R. M. Mendelson; Perth/AU Keywords: Cysts, Biopsy, Endoscopy, Ultrasound, MR, CT, Pancreas, Biliary Tract / Gallbladder, Abdomen DOI: /ranzcraocr2012/R-0130 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 31

2 Learning Objectives To review the imaging findings of cystic pancreatic lesions. To describe an imaging based classification of cystic pancreatic lesions. To present an algorithmic approach to the management of these lesions. Background Cystic pancreatic lesions have a diverse morphology and range from benign to malignant in nature. It is important to be familiar with their imaging features and characteristics on different modalities in order to be able to guide appropriate management. Particularly so since pancreatic surgery carries high morbidity, it is important to be familiar with the imaging features of benign lesions that can be followed up on a regular basis versus potential malignant lesions that need surgical attention. The management of small incidentally discovered pancreatic cystic lesions has been controversial. "Simple" cysts may be kept under observation (if clinically indicated), but larger or more complex cysts usually require definitive diagnosis. Benign asymptomatic lesions may not require surgery, but some are premalignant and require close observation or surgery. Imaging Findings OR Procedure Details METHODS: The radiologic information at Royal Perth Hospital was searched for the terms "pancreas" or "pancreatic" and "cyst" on CT abdomen or MRI reports between 1/08/2011 and 1/2/2012. Imaging findings were correlated with histopathology when available. RESULTS: A total of 32 patients were identified with pancreatic cystic lesions on imaging. 12 had simple cysts (i.e no prior history of pancreatitis, unilocular with smooth wall and no solid component) and 6 had pseudocysts (i.e prior history of pancreatitis) Page 2 of 31

3 The remainder 14 had features consistent with cystic neoplasm of the pancreas, 10 had subsequent aspiration that concurred with the imaging findings in all except one. DISCUSSION: Cytic pancreatic lesions can be classified into: Unilocular cysts Microcystic Macrocystic Cysts with solid conponent 1. Unilocular cysts Pancreatic Pseudocyst and intra- ductal papillary mucinous neoplasm (IPMN)- most common Mucinous cystadenoma Others- oligocystic serous cystadenoma, lymphoepithelial cyst, and cystic islet cell neoplasm. 2. Microcystic lesions-serous cystadenoma 3. Macrocystic lesions (multilocular cysts with fewer compartments, each > 2 cm) Mucinous cystadenoma, IPMN, and lymphoepithelial cyst. 4. Cysts with solid components- mucinous cystic neoplasm (mucinous cystadenoma and mucinous cystadenocarcinoma), IPMN, solid and papillary epithelial neoplasm, and solid neoplasms that may show cystic degeneration such as adenocarcinoma and islet cell tumors. TRUE CYSTIC NEOPLASMS: Most common are : Serous cystadenomas, Mucinous cystic neoplasms, and Intraductal papillary mucinous neoplasms Clinico-radiological course: Page 3 of 31

4 Benign:pseudocysts and serous cystadenomas Malignant: high malignant potentialmucinous cystic neoplasms,main- duct IPMNs, andsolid and papillary neoplasms Low malignant potential:side branch IPMNs 1. PSEUDOCYST: Any age M=F Unilocular or multilocular associated with pancreatitis located anywhere in the pancreas 2. SEROUS CYSADENOMA: > 60, F microcystic Central scar with calcification smooth lobulated contour minimal wall enhancement commonly located in the pancreatic head 3. MUCINOUS CYSTIC NEOPLASM: 50, F Unilocular or multilocular septated cystic lesion surrounding ovarian type stroma Usually located in body and tail of pancreas 4. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM: 40, M>F communicate with pancreatic duct Subtypes:main pancreatic duct type, isolated side branch type or a combination of both 5. SOLID AND PAPILLARY EPITHELIAL NEOPLASM: 35, F mixed cystic and solid components shows progressive accumulation of contrast agent usually located in the tail Page 4 of 31

5 MANAGEMENT ALGORITHM: 1. Symptomatic cysts, neoplasms with high malignant potential, and lesions >3 cm in size : Endoscopic ultrasound with fine-needle aspiration Surgical referral 2. For asymptomatic patients, an algorithmic approach as oulined in Figure 26 may be adopted. Images for this section: Fig. 1: Results illustrated as a pie chart Page 5 of 31

6 Fig. 2: 24 year old female with recent episode of pancreatitis, abdominal ultrasound showed a unilocular cystic lesion at the junction of the pancreatic head and body consistent with pseudcocyst. Complete resolution was noted on a repeat ultrasound performed 6 months later Page 6 of 31

7 Fig. 3: 44 year female with prior history of pancreatitis presented with abdominal pain, a transabdominal ultrasound showing pseudocyst. Page 7 of 31

8 Fig. 4: 55 year old female presented with abdominal pain, MRCP showed fluid fluid levels consistent with hemorrhage with a cyst Page 8 of 31

9 Fig. 5: Same patient had FNA that showed fungal elements in keeping with fungal infection of the pseudocyst Page 9 of 31

10 Fig. 6: 67 year old male, CT showed incidental finding of a large multicystic lesion in the head of pancreas. A punctate area of calcification is seen peripherally on the right lateral aspect of the lesion Page 10 of 31

11 Fig. 7: MRI liver of same patient, T2 trufi images: Multiseptated pancreatic head lesion in keeping with a serous cystadenoma. The lesion is predominantly T2 high signal with enhancement of the septae. Page 11 of 31

12 Fig. 8: EUS of the same patient shows multiple microcyst at the pancreatic head. FNA confirmed a serous cystadenoma Page 12 of 31

13 Fig. 9: CT abdomen of a 78 year old female with an incidental lobulated cystic lesion within the tail of the pancreas consistent with a serous cysadenoma Page 13 of 31

14 Fig. 10: FNA of the same patient confirming the presence of a lobulated microcystic lesion, FNA was non-diagnostic. However this was managed as a serous cystadenoma. Follow up CT an year after was stable Page 14 of 31

15 Fig. 11: 70 year old male incidentally noted to have pancreatic duct dilatation associated with pancreatic head mass on an abdominal ultrasound Page 15 of 31

16 Fig. 12: CT of the same patient confirming findings of the ultrasound, FNA- mucinous adenocarcinoma Page 16 of 31

17 Fig. 13: CT of a 77 year old female showing multiseptated cystic lesion within the pancreatic head. Page 17 of 31

18 Fig. 14: EUS of the same patient showing several simple cystic lesions within the head of the pancreas. FNA proved it to be low grade cystic mucinous neoplasm (such as mucinous cystic neoplasm or IPMN) Page 18 of 31

19 Fig. 15: 72 year old male without previous history of pancreatitis, CT showed cystic lesion at head of pancreas associated with pancreatic duct dilatation, thought to be either due to IPMN or mucinous cystic neoplasm Page 19 of 31

20 Fig. 16: Same patient had a CT 5 months later-coronal image shows unchanged appearance of the cystic solid mass. However new biliary tree obstruction as well as enlarging lymph nodes consistent with progression and malignant transformation. Page 20 of 31

21 Fig. 17: EUS of the same patient : large multi cystic lesion in the head of the pancreas with more solid component adjacent to these cysts, thought to be intraductal papillary mucinous neoplasm with malignant change, confirmed on FNA to be moderately differentiated adenocarcinoma Page 21 of 31

22 Fig. 18: This 72 year old male presented with abdominal pain, initial CT showed multiloculated hypo-attenuating pancreatic head and uncinate process lesion with focal cystic dilatation of the proximal pancreatic duct -thought to be consistent with combined main and side branch IPMN Page 22 of 31

23 Fig. 19: This lesion led to gastric oulet obstruction Page 23 of 31

24 Fig. 20: 3-D MRCP confirming a multi-loculated mass at the head and uncinate process of the pancreas, focal cystic dilatation of the main pancreatic duct is noted again Page 24 of 31

25 Fig. 21: EUS of the same patient showing a multi-cystic lesion at the pancreatic head. FNA proved it to be moderately differentiated adenocarcinoma Page 25 of 31

26 Fig. 22: CT of a 76 year male with complain of abdominal pain showing pancreatic duct dilatation but no discrete lesion Page 26 of 31

27 Fig. 23: EUS of the same patient showed cystic lesion in the body of the pancreas; FNAadenocarcinoma Page 27 of 31

28 Fig. 24: This 74 year old female presented to Emergency with with recurrent episodes of hypoglycemia. CT showed small cystic lesion in the head of pancreas, thought to be insulinoma. Page 28 of 31

29 Fig. 25: EUS same patient showing cystic lesion in the pancreatic head. FNA confirmed this to be an insulinoma. Page 29 of 31

30 Fig. 26: Management algorithm for patients with incidental pancreatic cysts. Page 30 of 31

31 Conclusion CT and MRCP are excellent modalities for initial diagnosis of pancreatic cystic lesions with endoscopic ultrasound (and aspiration biopsy) reserved for further characterization of such lesions if needed. Personal Information References Khan A, Khosa F, Eisenberg RL. Cystic lesions of the pancreas. AJR Am J Roentgenol. 2011;196(6):W S M M de Castro, J T Houwert, N A van der Gaag, T M van Gulik, O R C Busch, D J Gouma. Evaluation of a selective management strategy of patients with primary cystic neoplasms of the pancreas. Int J Surg. 2011;9(8): Lahat G, Lubezky N, Haim MB et al. Cystic tumors of the Pancreas: High Malignant Potential. IMAJ 2011;13: Sahani DV, Kadavigere R, Saokar A, Fernandez-del Castillo C, Brugge WR, Hahn PF. Cystic Pancreatic Lesions: A Simple Imaging-based Classifi- cation System for Guiding Management. RadioGraphics 2005; 25: Sahani DV, Miller JC, del Castillo CF, Brugge WR, Thrall JH, Lee SI. Cystic Pancreatic Lesions: Classification and Management. Journal of the American College of Radiology. 2009(6);5: Page 31 of 31