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8 Features for Differentiation of Cystic Lesions | Cystic Masses of the Pancreas - Part 3
8 Features for Differentiation of Cystic Lesions | Cystic Masses of the Pancreas - Part 3
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Serous Cystadenomas and Mucinous Cystadenomas | Cystic Masses of the Pancreas - Part 3
Serous Cystadenomas and Mucinous Cystadenomas | Cystic Masses of the Pancreas - Part 3
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Cystic Lesion in Pancreas and Solid and Pseudopapillary Tumor | Cystic Masses of the Pancreas - Part 3
Cystic Lesion in Pancreas and Solid and Pseudopapillary Tumor | Cystic Masses of the Pancreas - Part 3
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Image of Pancreatic Tail with Solid and Cystic Components  | Cystic Masses of the Pancreas - Part 3
Image of Pancreatic Tail with Solid and Cystic Components | Cystic Masses of the Pancreas - Part 3
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Unilocular Cysts - Interactive Question | Cystic Masses of the Pancreas - Part 3
Unilocular Cysts - Interactive Question | Cystic Masses of the Pancreas - Part 3
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Incidental Pancreatic Cysts - Role of EUS and Aspiration | Cystic Masses of the Pancreas - Part 3
Incidental Pancreatic Cysts - Role of EUS and Aspiration | Cystic Masses of the Pancreas - Part 3
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When and How to Follow Guidelines | Cystic Masses of the Pancreas - Part 3
When and How to Follow Guidelines | Cystic Masses of the Pancreas - Part 3
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Quiz - Head Tail | Cystic Masses of the Pancreas - Part 3
Quiz - Head Tail | Cystic Masses of the Pancreas - Part 3
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Quis - Neck of Pancreas Mass and Case with Tail of Pancreas | Cystic Masses of the Pancreas - Part 3
Quis - Neck of Pancreas Mass and Case with Tail of Pancreas | Cystic Masses of the Pancreas - Part 3
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Quiz - Tail Mass and Summary | Cystic Masses of the Pancreas - Part 3
Quiz - Tail Mass and Summary | Cystic Masses of the Pancreas - Part 3
2012contourcystadenomacystadenomascysticdiffuselydilatationdistallyductalepithelialhydatidintraductallesionsmucinousneoplasmneoplasmsoccurpancreaticpapillaryproximallypseudocystpseudocystsseroussolidUHN
Transcript

[MUSIC] Thank you for joining me for part three of my talk on cystic masses of the pancreas. I'm Korosh Khalili, and I work at the University Health Network and Mount Sinai Hospitals in Toronto. And I'm also an assistant professor at the

University of Toronto. So we're going to start this talk with the formidable slider head shown on the prior presentation which has eight features to look out for differentiation of oligocystic serous cystadenoma,mucinous cystadenoma, side-branch IPMN, and pancreatic pseudocysts. The first three features, that is age, sex, and location of the lesion, these are all useful in differentiating

mucinous cystadenoma from the remainder of the three entities. A lesion in a patient who's elderly, a lesion that is in a man, and lesion that is in the head of the pancreas, all those three features would be quite unusual for mucinous cystadenoma,

and would make us list it much lower down in our list of possibilities. The contour of the pancreatic lesion is also quite important. Mucinous cystadenomas and pancreatic pseudocysts

tend to have a smooth outer margin, whereas serous cystadenomas and side-branch intraductal papillary mucinous neoplasms both have lobulated outer margin. The pancreatic duct can be dilated in

mucinous and serous cystadenomas, but this is generally because of mass effect, and will be upstream or proximal. With side-branch intraductal papillary mucinous

neoplasm, there can be communication with the pancreatic duct with mucin pouring out, and if such thing occurs then there is dilatation of the duct distal to the side of attachment or diffusely. And with pancreatic pseudocyst there can be dilatation of the entire pancreatic duct because of chronic

pancreatitis. In terms of ductal communication, it is a relatively common feature, and this is what we look out for for side-branch IPMNs, and also for pancreatic pseudocysts. It is rarely described with mucinous cystadenomas.

Calcifications, if are seen, are usually central in serous cystadenomas, and peripheral in mucinous cystadenomas. Occasionally, they can be seen with side-branch IPMNs, and if they are seen with pseudocysts, they tend to be within the pancreatic parenchyma where they're a sign of chronic pancreatitis. Recently, internal debris within the cyst

has been described as a useful feature in separating or differentiating pancreatic pseudocysts from either cystic lesions. However, we do see occasionally debris within side-branch IPMNs, and occasionally we see hemorrhage within mucinous cystadenomas, which can be mistaken for debris. In this MRCP image, we can see

three cystic lesions in the pancreas. One is located in the head, one is in the body, and the other one is in the tail. Here we can see that there are lobulated outer margins to all these three lesion. This along with multiple little septations and cysts makes us think of the diagnosis of

serous cystadenoma. Because this patient has three of them, we would think about syndromes, and in this case, the diagnosis is one [INAUDIBLE] As opposed to disappearance/g, this patient has a large cystic lesion

in the tail, and we can see that the outer contour is nice and smooth. All the complicated portions of the cyst are located within it and don't extent to the contour. So this featured outer contour can be used to separate out mucinous cystadenomas from serous cystadenomas or intraductal papillary mucinous neoplasm. BLANK_AUDIO]

Here is a patient that has a cystic lesion within the tail of the pancreas. On ultrasound we can identify both solid and cystic components. On the CT examination we can see that the solid component, the enhancing solid component, is actually quite prominent. The appearance would be quite good for mucinous cystadenoma,

especially because of the nice rounded outer margin. But this patient was 16 years old, and in younger patients, another entity called solid and pseudopapillary epithelial neoplasms, or epithelial tumors of the pancreas, is also a possibility. These occur in younger women, aged 10 to 30, there is a

predilection for Asian and African populations. And about 15% of them tend to be malignant. Most of them are asymptomatic, and therefore they present a large size, but occassionally they can present with an acute hemorrhage. Most of the time these lesions are the head but they can also be in the pancreatic tail, and so the location is not a useful feature

in differentiating this tumor from others. As I mentioned, they can present quite large because they tend to be asymptomatic, and they have variable solid and cystic components. [BLANK_AUDIO]

On this T2-weighted and non enhanced fat saturated T1-weighted image of the pancreatic tail, we can see a large lesion that has solid and

cystic components. We know this is solid component because when we provide gadolinium, as I click here, we can see that these enhance. And so we can see that there is large solid component within this large tumor. [BLANK_AUDIO] However, solid and pseudopapillary

tumors can also be entirely solid, and they can also just be totally calcified, for example in this patient. Here's another patient. In fact, this was a young man with a mass in the head of the pancreas, and we can see that there is no cystic component. This is a solid mass, and not only was there a mass in the head of the pancreas, but also metastases within the pancreas. These tend to be low grade

malignancies, and so this patient actually had a ripples/g resection of the head of the pancreas and also hepatectomy. And patient did quite well afterwards with no evidence of recurrence. [BLANK_AUDIO] What

about unilocular cysts? We haven't talked about unilocular cysts separately. Here's a patient that has a large cyst in the body of the pancreas on this MR Image, T2-weighted MR Image. Here we

can see a large cystic component with no internal debris or septations. There is a bit of dilatation at the pancreatic tail. Sorry bit of dilatation at the pancreatic duct in the tail. What are the possibilities? Could this be as serous cystadenoma, mucinous cystadenoma, simple pancreatic cyst, a pseudocyst, or all of the above. [BLANK_AUDIO] And the answer is, all of the above. Unilocular cysts can be difficult, especially when they

are large, to make a diagnosis. The differential diagnosis is, not only the entities I've mentioned, but also simple epithelial cysts, as well as cystic neuroendocrine tumors. In this case, the patient underwent resection, and this was a mucinous cystadenoma. What to do with

incidental pancreatic cysts. It is very common for us to identify small

pancreatic cysts, and it is very difficult to know exactly what to do with them. It's important to know that the risk of malignancy of these cysts increases as they get larger, if the patient presents symptomatically, if there are solid nodules within it, and if there is main pancreatic duct dilatation associated with the lesion. So these are worrisome features for incidental pancreatic cyst. What is the role of endoscopic

ultrasound? Its best role is to actually guide fine needle aspiration. When fine needle aspiration is performed several different tests can be done. One of them is to check for amylase level. Amylase is a specific test to identify pancreatic pseudocysts. But unfortunately, it's not very sensitive. You can see the reported range is around 44%. CEA, carcinoembryonic antigen and Ca 19-9

are both good tests to separate out mucinous versus nonmucinous tumors, but they're not very good in telling benign from malignant lesions. Cytology on the other hand, is very specific in telling malignant lesions, but most often, cytology is negative, and therefore, it's not very sensitive in differentiating benign from malignant lesions. The best test is DNA Analysis, and this is an evolving area of knowledge,

but unfortunately DNA analysis is only available in very specialized centers. [BLANK_AUDIO] What to do with incidental pancreatic cysts. The possibilities are to resect them, to aspirate them, to follow them, or to forget about them.

Lesions that require surgery are typical-appearing main duct IPMNs also the mixed type variety. Typical mucinous cystadenomas, or solid and pseudopapillary epithelial neoplasms, or any cystic lesions that has an enhancing solid component. On the other side of the spectrum are typical serous cystadenomas, tiny little cysts, smaller than a centimeter, and especially when these occur in elderly patient. One

might decide that we can do infrequent or no followup on these lesions. The group in the middle, to aspirate and be a little more aggressive, or to follow up and be less aggressive, depends on their appearance and the clinical features. Patients who are symptomatic, who have lesions that are greater than three centimeters, where we see a solid nodule, a small solid nodule, or if there is

main duct dilation, these are features that will push us to aspirate, and try to get a better handle on a diagnosis. On the other hand, lesions that are asymptomatic or small, without solid component, and no involvement of the main duct, we can just follow these. How often do we need

to follow these? There is a great study, produced at the American Journal of the Gastroentorology, where 144 incidental pancreatic cysts greater

on 1 cm were followed. They had excluded typical-looking serous cystadenomas and lesions that would require surgery. So this is a group of patients that are generally troublesome. What they found was that the size of the lesion and presence of solid nodules were a predictor of growth. But also what they found very interestingly was that whether

the lesions were small or large, it took quite a while for them to start growing. And in fact, they recommend the first follow up interval to be 24 months after the diagnosis of an incidental pancreatic without worrisome features. Now we're going

to go back to the quiz that I originally showed in part one. Here we can see this patient has two lesions. The first is in the head.

This lesion has numerous tiny little cysts. It lies adjacent to the pancreatic duct but is not communicating with it. And it has a lobulated outer margin. So this is the typical appearance for serous cystadenoma. The lesion on the tail is a little different. It has larger cystic component, and we can see that it actually communicates with the main pancreatic duct. It's probably causing

some dilatation of the main pancreatic duct as well, downstream. So this is a typical appearance for a side-branch intraductal papillary mucinous neoplasm. And so the correct answer is number 2.

In this second patient we can see as cystic mass in the neck of the pancreas, and we can see that it has a lobulated outer margin, it has internal septations that radiate out from a central scar. And so this is a typical appearance for a

serous cystadenoma, and number 1 is the correct answer. [BLANK_AUDIO] And in our final case, we saw that there was a lobulated mass on this unenhanced CT scan. It's a cystic lesion arising exophytically from the tail of the pancreas. When we provide contrast, we can see

that there is, one or two septations within it that are enhancing. Okay, and we can see that it has a nice smooth outer margin. [BLANK_AUDIO] So in this case, this is a typical appearance

for a

mucinous cystadenoma in a typical location. Why hydatid cyst is not a possibility here and also pseudocysts is not a possibility here is because of enhancements within the septation,

which wouldn't be seen in either of those entities. So in summary, to differentiation of cystic pancreatic lesions can be difficult, but we can use a number of features in helping us make that differentiation. Age is useful because mucinous cystadenomas occur in a younger population than the other cystic lesions we talked about. They occur in middle age and younger women, and also in quiet

young patients. Solid and pseudopapillary epithelial neoplasm is a possibility. Also the sex of the patient is helpful because mucinous cystadenomas and solid and pseudopapillary epithelial neoplasms are unlikely to occur in male patients. Pancreatic pseudocysts and intraductal papillary mucinous neoplasms tend to present with symptoms, whereas pancreatic

mucinous cystadenomas and serous cystadenomas are unlikely to present with symptoms. The locations also useful for mucinous cystadenomas

because it's very unlikely to occur in the head of the pancreas. We talked about the contour differences. A smooth outer contour is seen in mucinous cystadenoma and solid and pseudopapillary epithelial neoplasms, as well as with pancreatic pseudocysts. Ductal dilatation is seen distally or diffusely

with intraductal papillary mucinous neoplasms. It may be seen with the other entities, but it's usually upstream or proximally to the lesion. [BLANK_AUDIO] Pancreatic ductal communication is also seen with intraductal

papillary mucinous neoplasms of the side-branch variety and with pancreatic pseudocyst, and debris has been described in pseudocyst to occur more often than with the other cystic lesions. Thank you for joining me for part three of pancreatic cystic neoplasms. [BLANK_AUDIO]

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