Pancreas: Pancreatic Cystic Neoplasia

Pancreatic Cystic Neoplasia (PCN)

Types

  • Serous Cystic Neoplasia (SCN)
    • Mostly Benign
    • Most Common in Head Mn
    • Most Common in Middle-Aged Females
  • Mucinous Cystic Neoplasia (MCN)
    • Premalignant Mn
    • Most Common in Body/Tail
    • Almost Exclusively in Elderly Women
  • Intraductal Papillary Mucinous Neoplasia (IPMN)
    • Sub-Types:
      • Main Duct (MD-IPMN)
        • High Malignancy Risk (> 60%)
        • Endoscopy: Gaping “Fish-Mouth” Papilla (Pathognomonic)
      • Branch Duct (BD-IPMN)
        • Lower Malignancy Risk
      • Mixed-Type IPMN
        • Involves Main & Branch Ducts
    • WHO Dysplasia Grades
      • Low Grade: Adenoma
      • Moderate: Borderline
      • High Grade: Carcinoma in Situ
    • High Incidence of Extrapancreatic Malignancy (10-50%)
      • Most Common: Colorectal Adenocarcinoma (#1 in US) & Gastric Adenocarcinoma
  • Solid Pseudopapillary Epithelial Neoplasm (SPEN)
    • Most Common in Young Women Age < 35 Mn
    • Have Malignant Potential

MCN 1

“Fish Mouth” Papilla of MD-IPMN 2

Diagnosis

  • First Step: MRCP
  • If Highly Suspicious for CA: Resection
    • Indications: MCN, MD-IPMN or SPEN
  • If Not Highly Suspicious: EUS-FNA
    • If Obviously Serous May Consider No EUS/FNA

MCN on MRI 3

MD-IPMN on MRCP 4

BD-IPMN on MRCP 5

BD-IPMN with Mural Nodule 6

Aspirate Findings

  CEA Amylase Cytology
SCN Low Low Cuboidal Cells, Glycogen Positive
MCN High Low Columnar Cells, Mucin Positive (Similar to IPMN)
“Ovarian-Type” Stroma
IMPN Variable High Columnar Cells, Mucin Positive (Similar to MCN)
SPEN – – Branching Papilla with Myxoid Stroma

Treatment

  • SCN: Conservative
    • Resection if Sx
  • MCN: Resection
  • IPMN:
    • MD-IPMN: Resection
    • BD-IPMN: Surveillance vs. Resection
      • Resection Indications: See Fukuoka Guidelines
      • If Patient Presents with Multiple Benign-Appearing BD-IMPN & a Single Concerning Cyst: Resect the Concerning Cyst & Monitor the Others
    • Mixed-Type IPMN: Resection
  • SPEN: Resection

Fukuoka Guidelines – Resection Indications for BD-IPMN

  • High Risk:
    • Jaundice
    • Mural Nodules
    • Main Duct > 10 mm
  • Worrisome:
    • ≥ 3 cm
    • Pancreatitis/Sx
    • Thickened Wall
    • Main Duct > 5 mm
    • LN

Mnemonics

Serous vs Mucinous Cystic Neoplasia – Location & Malignancy

  • Third Rule of Surgery: Don’t Mess With the Pancreas – “S&M” Written on the Pancreas
  • Head (Serous) to Body/Tail (Mucinous)
  • Benign (Serous/Side) to Malignant (Mucinous/Main/Mixed)

Mucinous Cystic Neoplasia Malignancy

  • M-M: Mucinous – Malignant

Most Common Ages at Presentation of Pancreatic Cystic Neoplasia

  • “Daughter-Mother-Grandma”
  • Daughter – SPEN Most Common in Young Women (SP-Sprouts)
  • Mother – MCN Most Common in Middle-Aged Women (M-Mother)
  • Grandma – SCN Most Common in Older Women (S-Senile)

References

  1. Cho HW, Choi JY, Kim MJ, Park MS, Lim JS, Chung YE, Kim KW. Pancreatic tumors: emphasis on CT findings and pathologic classification. Korean J Radiol. 2011 Nov-Dec;12(6):731-9. (License: CC BY-NC-3.0)
  2. Tanaka M. Current roles of endoscopy in the management of intraductal papillary mucinous neoplasm of the pancreas. Dig Endosc. 2015 May;27(4):450-457. (License: CC BY-4.0)
  3. Lee LS, Clancy T, Kadiyala V, Suleiman S, Conwell DL. Interdisciplinary management of cystic neoplasms of the pancreas. Gastroenterol Res Pract. 2012;2012:513163.(License: CC BY-3.0)
  4. Takuma K, Kamisawa T, Tabata T, Kurata M, Honda G, Horiguchi S. Main-duct intraductal papillary mucinous adenoma of the pancreas. World J Surg Oncol. 2011 Nov 23;9:153. (License: CC BY-2.0)
  5. Machado NO, Al Qadhi H, Al Wahibi K. Intraductal Papillary Mucinous Neoplasm of Pancreas. N Am J Med Sci. 2015 May;7(5):160-75. (License: CC BY-NC-SA-3.0)
  6. Paiella S, De Pastena M, Esposito A, Salvia R, Morigi C, Bassi C. Selective agenesis of pancreatic isthmus parenchyma with preservation of main pancreatic duct continuity, a very rare entity: Case report. Int J Surg Case Rep. 2015;6C:169-71. (License: CC BY-NC-ND-3.0)