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![Serous cystic neoplasm
• Have predilection for the head of the pancreas and occur in patients with a higher
median age.
• 60-70 years of age (Grandmother lesion) [Grandmother is the head of the family]
• 15-25% of all cystic neoplasms of pancreas
• Are almost always benign
• Presentation
• Vague abdominal pain
• Weight loss
• Obstructive jaundice
Associated with mutation in VHL gene in chromosome 3](https://image.slidesharecdn.com/cysticneoplasmofpancreas-240511072849-4aae1675/75/Details-about-Cystic-neoplasm-of-pancreas-pptx-8-2048.jpg)
![Mucinous cystic neoplasm
• MC cystic neoplasm
• Mucin producing cystic neoplastic tumors
• Lack communication with MPD
• Benign to invasive spectrum present
• Women at the 5th decade of life (mother)
• Men are rarely affected
• Found in body and tail of pancreas [Middle]
• Features Incidental discovery, vague abdominal pain](https://image.slidesharecdn.com/cysticneoplasmofpancreas-240511072849-4aae1675/75/Details-about-Cystic-neoplasm-of-pancreas-pptx-11-2048.jpg)
![BD-IPMN
• BD-IPMN involves dilation of the pancreatic duct side branches that
communicate with MPD but doesn’t involve the MPD
• Types
• Unifocal
• Multifocal [ Multiplicity of the cysts favor diagnosis if BD-IPMN]
• All cysts with worrisome features on CT/MRI should undergo EUS and all
cysts with high-risk features MUST be resected](https://image.slidesharecdn.com/cysticneoplasmofpancreas-240511072849-4aae1675/75/Details-about-Cystic-neoplasm-of-pancreas-pptx-19-2048.jpg)
![What to do with BD-IPMN?
• Asymptomatic patients/ no worrisome features
• Depends upon multiple factors Age, Comorbidities AND size of the cyst
• If cyst > 3cm and asymptomatic Surgery
• If cyst 2-3 cm consider for resection/ observation depending on age and physical
condition
• If cyst < 2cm Surveillance
• Symptomatic patients/ High-risk features
• Surgical resection [See in later slides]](https://image.slidesharecdn.com/cysticneoplasmofpancreas-240511072849-4aae1675/75/Details-about-Cystic-neoplasm-of-pancreas-pptx-20-2048.jpg)
![• Radiographic features in IPMN
• CT scan shows
• Dilated MPD
• Cysts (various sizes)
• Mural nodules
• MRCP and EUS
• Evaluation of patients with suspected IPMN
• MRCP allows localization of mural nodules, pretreatment
classification of suspected side branch OR main duct IPMN
• EUS allows assessing pancreatic duct fluid assessment as well as
assessment of solid components of neoplasm.
• Cytology assessment
• Mucin rich fluids with variable cellularity
• Columnar mucinous cells with variable atypia
• CEA > 192ng/mL [ indicates presence of mucinous
metaplasia]](https://image.slidesharecdn.com/cysticneoplasmofpancreas-240511072849-4aae1675/75/Details-about-Cystic-neoplasm-of-pancreas-pptx-24-2048.jpg)
![Treatment
• Partial pancreatectomy [primary treatment for high risk lesions]; extent of
resection is unknown
• For BD-IPMN Resection should target the lesion of concern; Surgical decision is
therefore straight forward.
• For MD-IPMN Not always possible to determine the extent of microscopic
abnormality
• In absence of diffuse polyps or enhancing nodules, right sided pancreatectomy is preferred.
• Intraoperative frozen section of the pancreas neck margin is obtained total pancreatectomy
is done in patients with high-grade dysplasia or invasive carcinoma](https://image.slidesharecdn.com/cysticneoplasmofpancreas-240511072849-4aae1675/75/Details-about-Cystic-neoplasm-of-pancreas-pptx-29-2048.jpg)
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Details about Cystic neoplasm of pancreas.pptx
- 1. Cystic neoplasm ofpancreas Nabin Paudyal
- 3. Introduction • Second mostcommon cause of pancreatic neoplasm after pancreatic adenocarcinoma • Guidelines for the management of cystic neoplasm continues to evolve
- 4. Classification of cysticneoplasms 1. Serous cystic neoplasm 2. Mucinous cystic neoplasm 3. Intra ductal papillary mucinous neoplasm 4. Solid pseudopapillary neoplasm
- 8. Serous cystic neoplasm •Have predilection for the head of the pancreas and occur in patients with a higher median age. • 60-70 years of age (Grandmother lesion) [Grandmother is the head of the family] • 15-25% of all cystic neoplasms of pancreas • Are almost always benign • Presentation • Vague abdominal pain • Weight loss • Obstructive jaundice Associated with mutation in VHL gene in chromosome 3
- 10. • On pathologicalexamination • Gross • Large, well-circumscribed masses, evenly distributed in pancreas • Microscopic • Multiloculated, glycogen-rich small cysts, cuboidal • Radiological examination • CT scan • Central calcification with radiating septa giving the sun-burst appearance • EUS • Better delineation of the CT scan features • Cystic fluid protein expression Helps differentiate IPMN and SCN • Management • Pancreatectomy (in uncertain diagnosis and symptomatic serous cystadenomas • If patients with tumor > 4 cm Resection of the SCN is appropriate
- 11. Mucinous cystic neoplasm •MC cystic neoplasm • Mucin producing cystic neoplastic tumors • Lack communication with MPD • Benign to invasive spectrum present • Women at the 5th decade of life (mother) • Men are rarely affected • Found in body and tail of pancreas [Middle] • Features Incidental discovery, vague abdominal pain
- 12. • Pathology • Microscopic •Presence of mucin rich cells and ovarian-like stroma surrounding the cyst • Estrogen and progesterone staining is positive • Radiological features • CT scan Solitary cyst with fine septations and a rim of calcification (eggshell calcification) • Cystic fluid aspirate • Mucin rich-aspirate, high CEA levels (>192 ng/mL) and low amylase • Management • Pancreatic resection as MCN has malignant potential • Adjuvant systemic chemotherapy after surgical resection when node-positive disease.
- 13. Intraductal papillary MucinousNeoplasm • Mucinous epithelial neoplasms Arise from the main pancreatic ducts or branch ducts or both. • Typically manifest at 6th-7th decade of life • IPMN encompass wide spectrum of epithelial changes • Histopathologic grading includes low, moderate or high grade dysplasia and presence/ absence of invasive malignancy • Subtypes of IPMN • Divided by the pattern of duct involvement • Branch Duct-IPMN only small side branches affected • Main Duct-IPMN MD-IPMN • BD-IPMN that extend into the main duct often leading to upstream dilation Mixed-type IPMN
- 14. What is normalsize of pancreatic duct?
- 15. What to dowhen IPMN is encountered? • There are worrisome and high risk factors that are used to stratify the lesion when encountered • Stratify the patient as per risk • Genetic mutations to evaluate • KRAS • P53 • MUC
- 19. BD-IPMN • BD-IPMN involvesdilation of the pancreatic duct side branches that communicate with MPD but doesn’t involve the MPD • Types • Unifocal • Multifocal [ Multiplicity of the cysts favor diagnosis if BD-IPMN] • All cysts with worrisome features on CT/MRI should undergo EUS and all cysts with high-risk features MUST be resected
- 20. What to dowith BD-IPMN? • Asymptomatic patients/ no worrisome features • Depends upon multiple factors Age, Comorbidities AND size of the cyst • If cyst > 3cm and asymptomatic Surgery • If cyst 2-3 cm consider for resection/ observation depending on age and physical condition • If cyst < 2cm Surveillance • Symptomatic patients/ High-risk features • Surgical resection [See in later slides]
- 21. MD-IPMN • MD-IPMN ischaracterized by abnormal cystic dilation of MPD with columnar metaplasia and thick mucinous secretions • Types • Focal • Diffuse • MD-IPMN have 30-50% risk of harboring invasive pancreatic cancer. Hence, surgical resection is the cornerstone in the management of MD-IPMN.
- 23. • Clinical features •50% abdominal pain • 25% Acute pancreatitis • Note the following • Jaundice • Raised Alkaline phosphatase • Presence of Mural nodule • Diabetes • Dilated MPD of > 7mm or larger • All of these indicate as predictors of malignancy in patients with MD-IPMN
- 24. • Radiographic featuresin IPMN • CT scan shows • Dilated MPD • Cysts (various sizes) • Mural nodules • MRCP and EUS • Evaluation of patients with suspected IPMN • MRCP allows localization of mural nodules, pretreatment classification of suspected side branch OR main duct IPMN • EUS allows assessing pancreatic duct fluid assessment as well as assessment of solid components of neoplasm. • Cytology assessment • Mucin rich fluids with variable cellularity • Columnar mucinous cells with variable atypia • CEA > 192ng/mL [ indicates presence of mucinous metaplasia]
- 25. Mixed type IPMN •Mixed IPMN includes side branch IPMN that has extended to involve main pancreatic duct to varying degree • Concern for mixed type IPMN should be raised in individuals with side branch cysts who exhibit upstream dilation of the pancreatic duct • Similar in behavior to MD-IPMN • 30-50% have risk of malignancy • Surgery is the main treatment method
- 26.
- 27.
- 28. Is there ahigh-risk Is there a Worrisome risk @I-TMC
- 29. Treatment • Partial pancreatectomy[primary treatment for high risk lesions]; extent of resection is unknown • For BD-IPMN Resection should target the lesion of concern; Surgical decision is therefore straight forward. • For MD-IPMN Not always possible to determine the extent of microscopic abnormality • In absence of diffuse polyps or enhancing nodules, right sided pancreatectomy is preferred. • Intraoperative frozen section of the pancreas neck margin is obtained total pancreatectomy is done in patients with high-grade dysplasia or invasive carcinoma
- 30. Survival outcomes • Survivalis dependent upon the invasive component of the IPMN lesion. • Following resection, surveillance of the remaining pancreas is advocated due to high risk of recurrence of IPMN or invasive malignancy • Decision to terminate surveillance will depend on the age, condition of the patient • Re-operation should be considered for patients with recurrence or progression of disease in the pancreas remnant
Editor's Notes
- #8 @ Benign VC-IS-MAD Border MIS Malignant Blastic-MINDS