Pancreatic Cysts. Darius C. Desai, MD FACS St. Luke s University Health Network

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1 Pancreatic Cysts Darius C. Desai, MD FACS St. Luke s University Health Network

2 None Disclosures

3 Incidence Widespread use of cross sectional imaging Seen in over 2% of patients having abdominal imaging for unrelated reasons More than half of incidental cysts are neoplastic Autopsy series 16% with atypical epithelium 3% with high grade dysplasia (carcinoma in situ) Laffan TA et al. AJR 2008;191:802 Spinelli, Ann Surg 2004; 239: ) Kimura W. Int J Pancreatol 1955;18:

4 Classification Pseudocysts Non-neoplastic pancreatic cysts Pancreatic cystic neoplasms

5 Pseudocysts 15-30% of pancreatic cysts 50% of pancreatic cysts in patients with a history of pancreatitis Can only be called a pseudocyst if no cyst was seen on pre-pancreatitis films Fernandez-del Castillo et al. Arch Surg 2003;138:427

6 Non-Neoplastic cysts Infectious Congenital Duplication Retention Lymphoepithelial

7 Neoplastic Serous Cystadenomas Serous Cystadenocarcinoma Mucinous Cystic Neoplasm IPMN Solid pseudopapillary tumor Cystic variants of solid tumors Cystic ductal adenocarcinoma Cystic neuroendocrine tumor Cystic acinar cell carcinoma

8 Should we resect all cysts? Ensures removal of all malignant cysts Minimizes the risk of allowing malignant lesions to progress Subjects patients to unnecessary and morbid operations Horvath KD Am J Surg 1999;178:269-74

9 Questions? Is this malignant? What is the malignant potential? Can the cyst be observed?

10 Serous Cystadenoma Benign Women in their 60 s (7 th decade) F/M ratio 3-4:1 Mean size 5-7cm at time of diagnosis Evenly distributed throughout the pancreas Galanis et al. J Gastrointes Surg 2007;11: Sakorafas et al. Cancer Treat Rev 2005;31:507-35

11 Serous Cystadenoma Asymptomatic Vague symptoms Biliary obstruction rare Symptomology related to cyst size Tseng JF et al. Ann Surg 2005;242:

12 Serous Cystadenocarcinoma 3% of serous tumors Diagnosis by characteristic imaging Honeycombing 20% have a central scar or calcification EUS Lobular macro and microcystic lesion Cao et al. Surg Oncol Clin NA. 2010; 272

13 Management Operative intervention for tumors greater than 4cm Symptomatic Observe asymptomatic lesions with serial CT No progression at 69 months Katz MH et al. J Am Coll Surg 2008;207: Bassi et al. World J Surg 2003;27:319-23

14 Solid Pseudopapillary Tumors Rare Growth rate can be dramatic Young women less than 35 Commonly in the body and tail Usually present with an abdominal mass Treatment is resection

15 Mucinous Cystic Neoplasms Secretes mucin, but does not communicate with the pancreatic duct Ovarian like stroma Women, usually in the 5 th -7 th decade Predominantly in the body and tail Reddy RP et al. Clin Gastroenterol Hepatol 2004;2:1026

16 Mucinous Cystic Neoplasms Symptoms are more common than in Serous tumors Abdominal pain Nausea Dyspepsia Symptoms are highly suggestive of malignancy DM Jaundice Weight loss Greishop NA et al. Am Surg 1994;60:509-14

17 Mucinous Cystic Neoplasms Imaging features include a unilocular or septated cyst that may include wall calcifications

18 Mucinous Cystic Neoplasms Factors associated with malignant transformation Larger size Thickened or irregular cyst wall Internal solid component Calcification of the cyst wall

19 Mucinous Cystic Neoplasms Slow process of malignant degeneration Atypia, dysplasia, carcinoma in situ and invasive carcinoma in the same tumor Age difference between patients with benign and malignant tumors (15 years) K-ras mutations in the cyst fluid Bartsch et al. Ann Surg 1998;228:79-86

20 Mucinous Cystic Neoplasms CT Thick walled Septated MRI with MRCP No communication with the pancreatic duct (IPMN) EUS Differentiates mucinous from non-mucinous CEA>192 ng/ml (80% accurate) CEA>6000 ng/ml suggestive of malignancy Brugge WR et al. Gastroenterology 2004;126:

21 Mucinous Cystic Neoplasms Treatment is surgical resection Lymphadenectomy for invasive disease Resect metastases with the tumor Malignant potential ranges from 6-36% Fernandez-del Castillo C et al. Surg Clin North Am 1995;75:

22 Mucinous Cystic Neoplasms Survival is dependent on extent of invasion 5 year survival for invasive MCN 15-33% 6 month cross sectional imaging 100% five year survival for non-invasive MCN No need for follow-up Reddy RP et al. Clin Gastroenterol Hepatol 2004;2: Sakorafas et al. Cancer Treat Rev 2005;31:507-35

23 IPMN Mucin secreting neoplasm that communicates with the pancreatic duct Male=Female Typically diagnosed between ages year lag time between benign and malignant degeneration Dilatation of the pancreatic duct Main duct IPMN Branch duct IPMN Mixed type IPMN Salvia R et al. Ann Surg 2004;239:678-85

24 IPMN 50% are located in the head of the pancreas 80% are multifocal or diffuse Account for 20% of surgical resections Gourgiotis S et al. Eur J Surg Oncol 2007;33:678-84

25 IPMN Non-specific symptoms Vague abdominal pain Nausea Vomiting Back pain Biliary and pancreatic duct obstruction Weight loss, jaundice and worsening DM Associated with invasive disease Raut CP et al. Ann Surg Oncol 2006;13:582-94

26 IPMN Patients with IPMN are at increased risk of other extra-pancreatic tumors Gastric Colorectal (MUC 2) -Genetic mutations (Different than adeno ca) DPC4 MUC2 Telomerase LOH p16 and p53 Fritz S et al. Ann Surg 2009;239:440-47

27 CT IPMN

28 IPMN Believed to be an adenoma to carcinoma sequence Risk of malignancy (includes carcinoma in situ) Main duct 60-90%, mean of 70% (two-thirds are invasive) Branch duct 6-46%, mean of 25% (invasive ca in 0-31%, mean of 17%) Tanaka M, Pancreatology 2012;12:

29 EUS Cyst fluid CEA IPMN Discriminates mucinous from non mucinous tumors Cyst fluid DNA and high amplitude mutations are associated with malignant IPMN htert (human telomerase reverse transcriptase) is strongly associated with malignant IPMN Gastrointest Endosc 2009;69: Pancreas 2012

30 Sendai Consensus Guidelines 2006 Resection for cysts that meet the following criteria Symptomatic Main duct dilitation >6mm Cysts with mural nodules Positive cytology Size>3cm

31 IPMN 2006 Criteria 97% sensitive 2006 Criteria not specific (29%) Cyst size and non-specific symptoms are poor predictors of malignancy Walsh RM et al. Surgery 2008;144:677-84

32 Surgery Pre-operative diagnosis matched pathology in 47% of cases Mucinous vs Non-mucinous correct 74% Pathology upgraded from preoperative diagnosis in 7% 20% resections were ultimately benign Cho CS et al. Ann Surg Oncol 2013;20:

33 IPMN Branch duct IPMN observation 35 elderly patients Median overall survival 52 months Disease specific survival 55 months Suggests elderly patients can be observed safely Piciucchi M et al. Digestive and Liver Disease 2013;45:584-88

34 IPMN 349 patients with branch duct IPMN, without nodules. 91% were followed without an operation. Range 1-16 years (median 3.7 years) Maguchi et al. Pancreas 2011;40:364-70

35 IPMN MGH Asymptomatic, incidentally discovered small (<2cm cysts) had a risk of malignancy of 3% Tseng JF et al. Ann Surg 2005;242:

36 2012 Consensus Guidelines Main Duct IPMN >5mm without other causes of obstruction Main pancreatic duct dilatation 5-9mm is a worrisome feature Main pancreatic duct dilatation 10mm or greater is a high risk stigmata Tanaka M, Pancreatology 2012;12:

37 2012 Consensus Guidelines Branch duct IPMN High risk stigmata and worrisome features introduced Those with worrisome features should have EUS Tanaka M, Pancreatology 2012;12:

38 2012 Consensus Guidelines High risk stigmata Obstructive jaundice with a cystic lesion in the head of the pancreas Enhancing solid component within the cyst Main pancreatic duct dilatation 10mm or greater All patients with high risk stigmata and are medically fit should undergo resection without further testing Tanaka M, Pancreatology 2012;12:

39 2012 Consensus Guidelines Worrisome features Cyst 3cm or greater Thickened/enhancing cyst wall Non-enhancing mural nodule Main pancreatic duct 5-9mm Abrupt change in main pancreatic duct caliber with distal pancreatic atrophy lymphadenopathy

40 2012 Consensus Guidelines Investigation CT or MRI with MRCP Asymptomatic <1cm cyst No further work up (invasive carcinoma uncommon) Follow up still required

41 2012 Consensus Guidelines Investigation for cysts >1cm Pancreatic protocol CT or MRI with MRCP All cysts with worrisome features should have EUS to stratify the risk of the cyst Cysts >3cm without worrisome features can be considered for EUS to verify the absence of thickened walls or mural nodules

42 2012 Consensus Guidelines Surgery for IPMN Removal of tumor and lymph nodes with a negative margin High grade dysplasia at margin-resect Low to moderate grade dysplasia-controversial PanIN 1A or 1B should be considered negative margin All patients should be counseled of the possibility of total pancreatectomy White R et al. J Am Coll Surg 2007;204: Farnell MB J Gastrointest Surg 2008;12:414-16

43 Margin Evaluation 26% had positive margin on final pathology with negative intra-op margin Frozen section when there is a concern for invasive disease at margin White R et al. J Am Coll Surg 2007;204:987-93

44 2012 Consensus Guidelines Surgery for branch duct IPMN Proposed high risk factors Rapidly increasing cyst size High grade atypia rather than positive cytology Kang MJ et al. Clin Gastroenterol Hepatol 2011;9:87-93 Pitman MB et al Pancreatology 2008;8:277-84

45 Branch duct IPMN Surgery 148 patients Jaundice MPD>5mm Mural nodule >5mm Elevated CA 19-9 Positive cytology CEA in pancreatic fluid >30ng/ml Only mural nodule >5mm and CEA>30ng/ml Positive predictive value is 100% Negative predictive value is 96.6% Hirono et al. AHPBA 2013:13.

46 2012 Consensus Guidelines Multifocal IPMN Pancreatic field defect 25-41% of branch duct IPMN Treatment should mirror Unifocal BD-IPMN Survey remaining region Threshold for total pancreatectomy lower in patients with strong family history of pancreatic adenocarcinoma Schmidt CM et al. Ann Surg 2007;246: Shi C et al. Clin Cancer Res 2009;15:

47 Multi-focal IPMN

48 2012 Consensus Guidelines Follow up of Non-resected lesions Without high risk stigmata 3-6 month MRI/MRCP or CT to establish stability Concern over pancreas developing adenocarcinoma in a gland with IPMN MSKCC 6 month imaging for 2 years and if stable then yearly

49 2012 Consensus Guidelines Follow up of resected patients Field defect 0-20% five year recurrence rate Non-invasive IPMN 0-10% Invasive IPMN 50-90% %yearly risk of adenocarcinoma Recurrence similar for invasive IPMN for partial pancreatectomy (67%) or total pancreatectomy (62%) Tanno S et al. Pancreatology 2010;10: Sakorafas Surg Oncology 2011;20:e Chari et al. Gastro 2002;123:1500-7

50 Follow up Surveillance should be performed after resection for IPMN, but the interval, modality and length remains unclear

51 Journal Am Coll Radiology 2010;7:766 Guidelines

52 2012 Consensus Guidelines

53 Surgery 240 Patients had surgery for BD-IPMN 152 initially, 88 after being followed Malignancy was seen in 10% 76% with carcinoma in situ and 95% with invasive cancer had high risk stigmata or worrisome features 11% with no worrisome features harbored malignancy Sahora K et al. ASA 2013

54 2012 Consensus Guidelines

55 Thank you