Details about Cystic neoplasm of pancreas.pptx

A presentation for Post Graduate General Surgery Residents about Cystic neoplasm of Pancreas

1. Cystic neoplasm of pancreas Nabin Paudyal

2. Introduction Second most common cause of pancreatic neoplasm after pancreatic adenocarcinoma Guidelines for the management of cystic neoplasm continues to evolve

3. Classification of cystic neoplasms Serous cystic neoplasm Mucinous cystic neoplasm Intra ductal papillary mucinous neoplasm Solid pseudopapillary neoplasm

4. 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

5. On pathological examination 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

6. M ucinous cystic neoplasm MC cystic neoplasm Mucin producing cystic neoplastic tumors Lack communication with MPD Benign to invasive spectrum present Women at the 5 th decade of life (m other ) Men are rarely affected Found in body and tail of pancreas [ M iddle] Features  Incidental discovery, vague abdominal pain

7. 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.

8. Intraductal papillary Mucinous Neoplasm Mucinous epithelial neoplasms  Arise from the main pancreatic ducts or branch ducts or both. Typically manifest at 6 th -7 th 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

9. What is normal size of pancreatic duct?

10. What to do when 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

11. 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

12. 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]

13. MD-IPMN MD-IPMN is characterized 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.

14. 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

15. 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]

16. 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

17. Management of IPMN

18. Based on Fukuoka guidelines @I-TMC Symptoms Size Features of cancer Life expectancy

19. Based on Fukuoka guidelines Is there a high-risk Is there a Worrisome risk @I-TMC

20. 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

21. Survival outcomes Survival is 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