Clinical approach to pancreatic cystic lesions

Programme details

1. Modearator and speaker
Dr. Nikhil Agrawal
GI-HPB Surgeon & Oncologist
Max Superspeciality Hospital, Saket
2. Panelists:
Dr. Vikas Singla
Gastroenterologist
Max Superspeciality Hospital, Saket
Dr. Asit Arora
GI-HPB Onco Surgeon
Max Superspeciality Hospital, Saket
Dr. Balkishan Gupta
Minimally invasive Surgeon
QRG Health City, Faridabad
Dr. Manu Shankar
General and Bariatric Surgeon
Fortis Escorts Hospital, Faridabad

Discussion

Introduction

• Increasingly diagnosed incidentally
• Sequalae of pancreatitis
• Approximately 1-3.5% malignant
• Treatment options range from observation to radical surgery
• Depends on malignant potential 
• Highest malignant risk in mucinous cysts
• Pseudocyst is treated if symptomatic or complicated

Types

Benign/ inflammatory lesions

• Pseudocysts/ WOPN
• Infectious cyst
• Retention cyst
• Lymphoepithelial cyst
• Congenital cyst
• Serous cystadenoma

Cystic lesions with malignant potential

• Intraductal papillary mucinous neoplasm
• Mucinous cystadenoma
• Cystic pancreatic neuroendocrine neoplasms
• Solid pseudopapillary neoplasms

Cystic malignant tumours (malignant tumours with cystic degeneration)

• Cystic ductal adenocarcinoma
• Acinar cancers

History and presentation

• H/o severe pain abdomen
• H/o Pancreatitis
• Chronic pancreatitis

• Pain abdomen
• Jaundice (yellowing of eyes, skin and urine)
• Feeling of fullness after food or bloating
• Lump in the abdomen

• Incidental

Distinguishing between lesions

• History and clinical
• Radiological/ EUS
• Fluid analysis

Work-up

• Ultrasound
• CECT abdomen
• CEMRI
• Endoscopic ultrasound

Radiological features

• Location
• Ductal relation
• Internal content
• External contourWall
• Septal enhancement

High malignancy risk

• Mural nodules
• Nearby mass
• Thick septa
• Dilated PD

Pathological features

Cyst fluid analysis

• CEA, CA-125, mucin content, cytology, DNA content, detection of genetic mutations
• Cyst fluid glucose
• CEA most reliable
  Sensitivity and specificity 73% and 84%
• Cyst fluid mucin content analysis
  MUC1 pancreatic adenocarcinoma
  MUC 6 serous cysts
  Cysts with MUC 5A, MUC2 and MUC 1 have the highest risk of being malignant
• Molecular analysis
  K-ras mutation and >2 loss of heterozygosity was 96.2% specific for malignancy

Pseudocyst / WOPN

• Collection of inflammatory debris lined by a false wall of granulation tissue
• May be asymptomatic, symptomatic, infected or complicated (bleed, obstruction [gastric, biliary], rupture)
• Cyst fluid high amylase and lipase
• CT – unilocular hypodense cystic lesions surrounded by smooth dense wall having contrast enhancement
  • Radiological evidence of pancreatitis
• Management
  • Observation
  • Internal drainage
    • Endoscopic
    • Surgical

Management - observation

• Simple cyst
• Lymphoepithelial cysts
• Small serous cystic neoplasm
• Small branch duct IPMN
• Intraparenchymal spleen

Surgery

• Those deemed malignant and at risk of malignancy
• Depending on the location and size
  • Whipple
  • Distal pancreatectomy
    • Spleen preserving
  • Central pancreatectomy
  • Enucleation
• Approach
  • Open
  • Laparoscopic