PSEUDOCYST OF PANCREAS AND BENIGN CYSTIC NEOPLASMS

Dr. E.Kaushik KumarStanley Medical College Hospital,Chennai

குறள் 84

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Chronic Collection of amylase-rich fluid enclosed in a non-epitheliazed wall of fibrous(collagen) or granulation tissue.

Follow after Acute Pancreatitis(5-15%) Chronic Pancreatitis(20-38%) Trauma

4- 8 weeks from the onset of AP Single or multiple or multilobulated

Duct leak Intrapancreatic or extend beyond into

other cavities or compartments Regress spontaneously 50% Chronic pseudocysts may persist

Thick-walled or large (over 6 cm in diameter)

Lasted for a long time (over 12 weeks) Arisen in the context of chronic pancreatitis

Symptoms and Complications Pain Fullness Satiety Loss of weight

Complications include Abscess /systemic sepsis SMV/PV thrombosis Intracystic

hemorrhage/pseudoaneurysms Peritonitis/intraperitoneal bleeding Pressure efects Pancreatico pleural fistula

INVESTIGATIONS

Ultasonogram CT EUS ERCP MRCP FNA

US,CT- Identification of pseudocyst and differentiates from abscess

EUS- Guided FNA Differentiates between chronic pseudocyst and cystic neoplasms

ERCP/MRCP- ductal communication,ductal anomalies, chronic pancreatitis,plan treatment

CEA -High level in mucinous tumours >400ng/ml

Amylase- Level usually high in pseudocysts, but occasionally in tumours

Cytology- Inflammatory cells in pseudocyst

INTERVENTION

Symptoms

If complications develop

Distinction has to be made between a pseudocyst and a tumour

Internal drainage vs external drainage Endoscopic

Percutaneous

Surgical –Open/Laparoscopic

Percutaneous

Usually avoided

Recurrence

Pancreatico-cutaneous fistula

Endoscopic

Distance of pseudocyst to the gastrointestinal wall <1 cm

Size>5 cm, gut compression, single cyst, mature cyst, no disconnected segment of pancreatic duct

Symptomatic, failure with conservative treatment, persistence over 4 weeks or longer

Location of transmural approach based on maximal bulge of the pseudocyst to the adjacent wall

Mature cyst, perform pancreatography first, prefer transpapillary approach, if feasible

Check for debris within pseudocyst Neoplasm and pseudoaneurysm

have to be ruled out

Surgical Complications Drainage internally

Stomach Duodenum Jejunum

Recurrence <5%

Newer techiques

Forward-viewing echoendoscope PFC puncture devices Combination devices Devices for maintenance of

cystenterostomy Multiple transluminal gateway

technique (MTGT)

CYSTIC NEOPLASMS

Second most common neoplasm of exocrine pancreas Mucinous cystic neoplasm Serous cystic neoplasm Intraductal papillary neoplasm

Mucinous cystic neoplasm

Most common Histologic spectrum from benign to

invasive carcinomas. MCNs contain mucin-producing

epithelium Mucin-rich cells and ovarian-like

stroma Estrogen and progesterone staining

are positive in most cases.

Frequently seen in young women, the mean age at presentation is in the fifth decade.

Men are rarely affected Body and tail of the pancreas Up to 50% of patients present with

vague abdominal pain. A history of pancreatitis may be found

in up to 20% of patients-common misdiagnosis of pseudocyst

CT Appearance Solitary cyst Fine septations Rim of calcification

Malignant Large tumour size Egg-shell calcification Mural nodule

Potential to turn to malignancy

Resection Curative No further surveilance needed

Serous cystic neoplasm

Higher median age Head of pancreas Vague abdominal pain,weight

loss,obstructive jaundice Large well circumscribed mass

CT appearance Central calcification with radiating septa “Sun-burst” appearance

Microscopic appearance Multiloculated,glycogen rich small cysts

Resection >4cm Rapidly growing Diagnosis of malignancy is uncertain

Intraductal papillary mucinous neoplasm

6th-7th decade Wide spectrum of epithelial

changes,including benign adenoma, borderline, carcinoma in situ, and invasive adenocarcinoma

Types Side branch Main duct Mixed

Side branch IPMNInvolves dilation of the pancreatic duct side branches that communicate with but do not involve the main pancreatic duct.

Focal/multifocal Malignant transformation directly

proportional to cystic dilatation 10-15% risk

Main duct IPMN

Abnormal cystic dilation of the main pancreatic duct with columnar metaplasia and thick mucinous secretions

Focal or diffuse 30%-50% risk of invasive cancer Surgical resection is the corner stone

of treatment –Partial Pancreatectomy

50% present with abdominal pain 25% present with AP Diagnostic confusion with – Chronic

Pancreatitis Risk of malignancy

Jaundice Elevated serum alkaline phosphatase level Mural nodules Diabetes Main pancreatic duct diameter of 7 mm

Mixed type

Side branch IPMN that has extended to involve the main pancreatic duct to a varying degree

Individuals with side branch cysts who exhibit upstream dilation of the pancreatic duct

Characteristics and management- similar to Main duct IPMN

Conclusion

Observation for patients with asymptomatic small (<3 cm) branch duct IPMNs that have no associated nodularity.

A plan for watchful surveillance with delayed intervention in these patients is reasonable because Risks for malignancy with small,

asymptomatic branch duct tumors is low Most Patients are older Time required to develop invasive malignancy

>patient’s life expectancy.