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Pancreas: Cystic Tumors of the Pancreas Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Pancreas ❯ Cystic Tumors of the Pancreas

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  • Cystic Lesions of Pancreas:
Lesions with Higher Malignant Potential
    - Mucinous cystic neoplasm (MCN)
    - Main duct type IMPN
    - Solid and pseudopapillary neoplasms
    - Cystic neuroendocrine tumors
  • Cystic Lesions of Pancreas
Lesions with Low Malignant Potential
    - Sidebranch IPMN
    - Serous microcystic adenoma
    - Post-inflammatory pseudocysts
    - Peripancreatic lymphangioma
  • Cystic Lesions of Pancreas
Worrisome Imaging Features
Larger Cysts with Internal Complexity
    - Cysts > 3 cm
    - Thickened irregular septations
    - Mural nodularity
    - Main duct dilation > 5 mm
    - No communication with main duct
    - Vascular encasement
  • “Patients with VHL can develop pancreatic cysts, serous cystadenomas, and pancreatic NETs. Pancreatic cysts are com- mon in VHL and may be seen in 42% of cases (range, 7%–72%). These are typically multiple and usually asymptomatic. Interestingly, pancreatic cysts may be the only manifestation in about 12% of patients at the time of initial VHL diagnosis.”


    Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Comprehensive State-of-the-Art Review 
Ganeshan D et al.
 RadioGraphics 2018 (in press)
  • “Serous cystadenomas occur in 11% of patients (range, 9%–17%) At histopathologic analysis, serous cystadenomas demonstrate well- demarcated multilocular clusters of small cysts, separated by thin fibrous septa. These cystic lesions are lined by cuboidal cells, without mucin or papillary structures. Both pancreatic cysts and serous cystadenomas tend to be asymptomatic, but larger lesions may cause nonspecific abdominal pain, and extensive cystic lesions replacing most of the pancreas may result in pancreatic insufficiency and diabetes mellitus.”


    Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Comprehensive State-of-the-Art Review 
Ganeshan D et al.
 RadioGraphics 2018 (in press)
  • “Pancreatic NETs develop in 15% of patients with VHL (range, 9%–17%) . The mean age of onset is 35 years, but NETs have been reported in patients as young as 13 years of age. About 53% of VHL-associated pancreatic NETs are multiple. Although any part of the pancreas may be involved, they are more common in the head and uncinate process of the pancreas. Pancreatic NETs associated with VHL manifest at a much younger age compared with that of sporadic NETs, and they are more commonly multifocal.The vast majority of these pancreatic NETs are nonfunctional tumors.”


    Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Comprehensive State-of-the-Art Review 
Ganeshan D et al.
 RadioGraphics 2018 (in press)
  • “Considering that less than 20% of pancreatic NETs associated with VHL are malignant, a conservative approach with a “watch-and-wait” strategy is an important part of the management of these tumors. Studies have shown that about 40% of NETs in VHL may be stable or even decrease in size. Surgical resection may be appropriate for pancreatic NETs in VHL when the tumor size is greater than 3 cm (or >2 cm for lesions in the head of the pancreas), the tumor doubling time is less than 500 days, there is a mutation in exon 3, or there is suspicion of regional nodal metastases.”


    Tumors in von Hippel–Lindau Syndrome: From Head to Toe—Comprehensive State-of-the-Art Review 
Ganeshan D et al.
 RadioGraphics 2018 (in press)
  • OBJECTIVE. The purpose of this study is to evaluate the diagnostic performance of MDCT in assessing tumor resectability in patients with borderline resectable pancreatic cancers after receiving neoadjuvant chemoradiation therapy (CRT) in comparison with those undergoing upfront surgery.

    
CONCLUSION.
    In patients with borderline resectable pancreatic cancers, neoadjuvant CRT did not signifi- cantly decrease the performance of MDCT for the prediction of local resectability. However, by considering post-CRT changes, such as nonprogression in tumor-vascular contact, MDCT may provide better sensitivity for locally resectable disease. 


    Preoperative MDCT Assessment of Resectability in Borderline Resectable Pancreatic
Cancer: Effect of Neoadjuvant Chemoradiation Therapy
Joo I et al.
AJR 2018; 210:1059–1065
  • “The most frequently encountered pancreatic cysts include IPMN, serous cystadenoma (SCA), mucinous cystic neoplasm with ovarian stroma (MCN), solid pseudopapillary epithelial neoplasm, cystic pancreatic neuroendocrine tumor (cPNET), and pseudocyst. Rare cysts include true epithelial cyst, lymphoepithelial cyst, and mucinous non-neoplastic cyst. IPMN is further subdivided into branch duct (BD), main duct, and combined forms.”


    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • “Malignancy rates in IPMN are reported as 12%-47% for BD-IPMN, whereas combined form and main duct forms have essentially identical malignancy rates of 38%-65% and 38%-68%, respectively.”

    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923. 


  • “Most diagnostic uncertainty is centered on pancreatic cysts <2.5 cm. Helpful queries include the following: (1) Is the cyst mucinous? (2) If mucinous, what is its relation to the main pancreatic duct (MPD)? and (3) If mucinous, are mural nodules present? Several studies suggest that referring physicians are comfortable with imaging surveillance for small BD-IPMN without mural nodules which is supported by pathology studies confirming a low rate of malignant transformation.”

    
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • 














    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

     

  • Categories
    <1.5 cm incidental pancreatic cyst
    1.5-2.5 cm incidental pancreatic cyst with MPD communication
    1.5-2.5 cm incidental pancreatic cyst without MPD communication or can not be determined
    >2.5 cm incidental pancreatic cyst
    Incidental pancreatic cyst in patient >80 years old

     

  • How long do you need to follow these patients?
    For most patients, we advocate 9- to 10-year follow- up, terminating at the age of 80 years For patients who are <65 years old at the time of initial cyst detection, a follow-up terminating at age 80 will exceed the 9- to 10-year length, but may be prudent ;such decisions regarding additional follow-up should be determined at the individual patient level.
    

















  • Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • 















    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • 















    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • 















    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • 















    Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • “The natural history of incidental pancreatic cysts remains uncertain, and our recommendations cannot be simple or entirely definitive. Since 2010, several multi-institutional and specialty society consensus papers, meta-analyses, and large-scale observational studies have appeared but the quality of evidence has been characterized as poor or inconclusive, and conclusions remain controversial.”

    
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • The following six elements must be reported when an incidental pancreatic cyst is detected on a CT or MRI study:
    - Cyst morphology, location
    - Cyst size
    - Possible communication with MPD
    - Presence of “worrisome features” and/or “high-risk
    - stigmata”
    - Growth on follow-up examination
    - Multiplicity

  • Five Common Principles of our Algorithm
    (1) All incidental cysts should be presumed mucinous, unless the cyst has definitive features of an alternative histology (eg, SCA) or has been proven by aspiration not to be mucinous. Such presumed mucinous cysts should be followed or considered for surgery. We generally recommend 9- to 10-year follow-up with varying schedules, based on initial size. If a cyst grows, the frequency of follow-up should increase and/or EUS with FNA should be considered.
    (2) Cyst size directs follow-up or intervention. Although our cyst size thresholds (ie, <1.5 cm, 1.5-2.5 cm, >2.5 cm) differ from the commonly used 3 cm threshold, our choices are sensitive to studies of surgically resected “Sendai-negative” cysts <3 cm, which have shown that high-grade dysplasia or frank malignancy may occur in cysts of this size.
    (3) Because the flowcharts apply to a range of cyst sizes, growth may require shifting from one flowchart to another, most commonly when a cyst grows from <1.5 to >1.5 cm. Such shifts may also be appropriate when a cyst is first discovered in patients who are close to 80 years of age, as described above). In general, a new 9- to 10-year follow-up period is not recommended when such a shift occurs; rather, decisions concerning total follow-up length should be tailored to the patient’s circumstance. Alternatively, it is appropriate to consider direct sampling of a growing cyst (ie, EUS and FNA).
    (4) Development of “worrisome features” or “high-risk stigmata,” as described above (“Reporting Considerations” section), should prompt EUS/FNA and surgical consultation. The exception is that cysts ≥3 cm without any additional “worrisome features” or “high-risk stigmata” can alternatively be followed.
    (5) Comparison with prior imaging studies is crucial, including those where the pancreas is frequently visualized, such as chest CT, spine CT or MRI, PET/ CT, and abdominal ultrasound. Prior studies should be reviewed for stability and features. The date of a prior study can be used as a baseline to establish a follow-up schedule.

  • Regardless of the modality, intravenous contrast, multiphase acquisitions, and thin sections for 3D visu- alization are generally needed. Sixteen-slice or greater multiple detector CT scanners acquire submillimeter slices with isotropic voxels and allow reformatted thicker slices (3-5 mm). Pancreatic-phase images should begin about 50 seconds after initiating the intravenous contrast injection. Injection rates of 4-5 mL/s may optimally display peripancreatic vasculature and maximize pancreatic enhancement. A second phase is recommended at approximately 80 seconds to evaluate the liver. 
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee.

    
Megibow AJ et al. 
 J Am Coll Radiol. 2017 Jul;14(7):911-923.

  • “Despite published guidance recommendations and reported awareness of them, fewer than half of follow-up recommendations for FCPL are consistent with the guidance and considerable variability persists among radiologists.”


    Focal Cystic Pancreatic Lesion Follow-up Recommendations After Publication of ACR White Paper on Managing Incidental Findings 
Mark D. Bobbin et al.
J Am Coll Radiol 2017 (in press)

  • “Nonadherence to management recommendations among our radiologists was particularly notable in the subset of cases in which no follow-up recommendation was made. Just over 40% of reports correctly followed ACR guidance by not providing a follow-up recommendation. Based on the algorithm, however, our radiologists should have provided a follow-up recommendation in almost 60% of this sample.”


    Focal Cystic Pancreatic Lesion Follow-up Recommendations After Publication of ACR White Paper on Managing Incidental Findings 
Mark D. Bobbin et al.
J Am Coll Radiol 2017 (in press)

  • “Radiologists may favor providing follow-up recommendations that more closely reflect the manage- ment algorithm preferred by ordering providers rather than those provided by outside organizations.”


    Focal Cystic Pancreatic Lesion Follow-up Recommendations After Publication of ACR White Paper on Managing Incidental Findings 
Mark D. Bobbin et al.
J Am Coll Radiol 2017 (in press)


  • Computed Tomography Angiography of the Thoracic Aorta 

    Scheske JA et al. 

    Radiol Clin N Am 54 (2016) 13–33

  • Computed Tomography Angiography of the Thoracic Aorta 

    Scheske JA et al. 

    Radiol Clin N Am 54 (2016) 13–33
  •  “The presence of a fatty component within a pancreatic tumor is highly suggestive of a benign lesion.” 


    Imaging features of rare pancreatic tumors 
M. Barrala, S.A. Faraound, E.K. Fishman, A. Dohan, C. Pozzesserea, M.-A. Berthelina,P. Bazeries, M. Barat, C. Hoeffel, P. Soyer 

  • “The prevalence of pancreatic cystic lesions on abdominal imaging has been reported to be between 2.6% to 19.6%. Pancreatic serous cystic neoplasms account for approximately 16% of primary cystic pancreatic neoplasms. Although magnetic resonance (MR) imaging is frequently used for characterization of cystic pancreatic lesions, computed tomography (CT) remains the first line imaging modality due to more widespread availability. Most serous cystic neoplasms are benign and represent pancreatic serous cystadenomas (SCAs).


    The many faces of pancreatic serous cystadenoma: Radiologic and pathologic correlation L.C. Chu , A.D. Singhi, R.R. Haroun, R.H. Hruban, E.K. Fishman
Diagnostic and Interventional Imaging (In Press, Corrected Proof)
  • “Classically, pancreatic serous cystadenomas have been described as multilobulated multiloculated cystic masses with central stellate scars and calcifications . However, serous cystadenomas have a wide spectrum of CT appearance, ranging from unilocular cystic masses to hypervascular solid masses, which can mimic other benign and malignant pancreatic masses. Serous cystadenomas can be morphologically classified as polycystic (or microcystic), honeycomb, oligocystic, and solid patterns).


    The many faces of pancreatic serous cystadenoma: Radiologic and pathologic correlation 
        L.C. Chu , A.D. Singhi, R.R. Haroun, R.H. Hruban, E.K. Fishman
Diagnostic and Interventional Imaging (In Press, Corrected Proof)
  • Typical versus atypical features of pancreatic serous cystadenoma
  • Patterns of pancreatic serous cystadenoma: Microcystic pattern
    The microcystic pattern, or polycystic pattern, is present in 1–2% of all exocrine pancreatic tumors and in 70% cases of serous cystadenomas, and consists of a collection of cysts (usually more than 6) that range from a few millimeters up to 2 cm in size. Fine external lobulations are a common and characteristic feature. A fibrous central scar with or without a stellate pattern of calcifications, seen in 30% of cases, is highly specific for serous cystadenoma. Serous cystadenomas do not usually communicate with the pancreatic duct.
  • Patterns of pancreatic serous cystadenoma: Honeycomb pattern
    The honeycomb pattern is seen in ∼20% of cases, and consists of numerous tiny cysts that mimic a honeycomb or a sponge. These tiny cysts may be poorly depicted as individual cysts on CT. These serous cystadenomas appear as soft tissue or mixed attenuation masses depending on the size of the cysts and the amount of enhancing fibrous tissue
  • Patterns of pancreatic serous cystadenoma: Oligocystic pattern
    The oligocystic pattern also known as the macrocystic pattern is seen in less than 10% of cases. It is composed of fewer but larger (> 2 cm) cysts and lacks the central stellate scar . It may be difficult to differentiate the oligocystic variant from mucinous cystic neoplasms or side-branch intraductal papillary mucinous neoplasms (IPMNs). The presence of external lobulations favors serous cystadenoma over mucinous cystic neoplasms and IPMNs . Dilatation of the pancreatic duct is an unusual feature and may be seen in rare cases
  • Patterns of pancreatic serous cystadenoma: Solid pattern
    Rare cases of solid variant of serous cystadenoma have been described. These serous cystadenomas do not contain any cystic spaces on histopathology and the cells are arranged in nests, sheets, and trabeculae separated by thick fibrous bands. The stroma demonstrates avid contrast enhancement and accounts for the solid hypervascular appearance on CT. In other cases, the serous cystadenoma is not completely solid, but contains prominent stromal hyalinization with relatively few cystic components, which also imparts a solid hypervascular configuration on CT . Serous cystadenomas may also demonstrate intratumoral hemorrhage, which also contributes to the high density solid appearance of these lesions.
  • Cystic pancreatic lesions mimicking pancreatic serous cystadenomas
    As previously indicated, pancreatic serous cystadenoma exhibit a wide spectrum of heterogeneous pattern on CT. For example, the oligocystic pattern might be misinterpreted as a mucinous cystadenoma or mucinous cystadenocarcinoma, while the solid pattern might be misinterpreted as a solid NET or adenocarcinoma.
  • “MCNs almost exclusively present in middle-aged women at an average age of 40 to 50 years. In several large series, approximately 60% to 70% of patients presented with symptoms, most often abdominal pain, whereas the remainder were diagnosed incidentally on imaging.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “MCNs nearly always present as a solitary cyst in the body or tail of the pancreas.These lesions lack communication with the pancreatic duct and can have thickened walls or septae in more than half of cases. Mural nodules are predictive of malignancy, as is the case with IPMNs..”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “A solitary cyst in the body or tail of the pancreas, in a middle-aged woman, without ductal communication strongly suggests a diagnosis of MCN and eliminates the need for further evaluation prior to treatment.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Regarding definitive management, the current 2012 Fukuoka consensus guidelines recommend surgical resection for all MCN.Rationale includes the 17% to 18% risk of malignancy (high-grade dysplasia or invasive cystadenocarcinoma), the risk of future progression even in benign disease, current inability to predict which lesions contain or will progress to malignancy, and the characteristic presentation of a distal lesion in an otherwise young and healthy patient, allowing for a less morbid operation (ie, distal pancreatectomy with possible splenic preservation as opposed to pancreaticoduodenectomy) in patients with relatively low perioperative risk.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “On surgical pathology, diagnosis of MCN is confirmed by the presence of ovarian-type stroma . If invasive cystadenocarcinoma is noted, postoperative surveillance, as for PDAC, is recommended but has not been shown to improve prognosis. If there is no invasion noted on pathology, the patient is considered cured, with zero risk of recurrence based on several large case series,and no special oncologic surveillance is required.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Because MD-IPMNs carry a higher risk of malignancy at presentation and require immediate surgical resection, whereas the more commonly encountered BD-IPMNs are more likely benign lesions that can be managed nonoperatively, it is important to discern the variant of IPMN at the time of diagnosis to help guide management and determine prognosis.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • Selective surgical resection of only high-risk BD-IPMNs, as determined by either of the following: (1) high-risk stigmata of malignancy (clinical: obstructive jaundice; CT/MRCP: enhancing solid component or main duct greater than or equal to 10 mm); or (2) worrisome features (clinical: pancreatitis; CT/MRCP: main duct 5–9 mm, nonenhancing mural nodule, thickened/enhancing cyst wall, abrupt change in duct caliber with distal atrophy, lymphadenopathy, or cyst size greater than or equal to 3 cm) plus EUS confirmation of either main duct involvement (as discussed previously), mural nodule (as opposed to a ball of mucin), or cyst fluid cytology suspicious or positive for malignancy.
  • A population that requires special consideration is patients with hereditary pancreatic cancer, defined by at least 2 other first-degree relatives with PDAC. These patients are at increased risk of PDAC and, if presenting with BD-IPMN, should be offered surgical resection at a lower threshold (ie, if they present with any worrisome features on MRCP or CT). If not immediately operated on, such patients should be managed with close endoscopic and radiologic surveillance.
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Correa-Gallego and colleagues developed a preoperative nomogram to better predict high-grade dysplasia or invasive carcinoma in IPMNs prior to surgical resection. Weight loss, history of prior malignancy, male gender, and solid component were significantly associated with malignant MD-IPMNs, whereas solid component, weight loss, and cyst size were significantly associated with malignant BD-IPMNs.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “EUS-guided FNA of cyst fluid with subsequent cytologic analysis for high-grade atypical epithelial cells or obviously malignant cells is approximately 80% accurate at predicting malignant disease in IPMNs and MCNs.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Chemical analysis of cyst fluid, in particular CEA level, was suggested by some groups to predict malignancy but has not been reproducible. Molecular assessment of cyst fluid (eg, DNA analysis for oncogenic KRAS or GNAS mutations and/or amplifications), microRNA (miRNA) profiling, cytokine measurement (eg, of interleukin [IL]-1ß  and prostaglandin E2 [PGE2]), and mucin proteomic profiling may each improve prediction of malignancy but require further investigation.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Serous Cystadenoma(SCAs) are nonmucinous, benign cystic neoplasms of the pancreas, which can be observed rather than resected and, therefore, stand apart from most other types of pancreatic cystic neoplasms.Cyst lining is composed of cuboidal epithelial cells rich in glycogen. The more common microcystic variant is composed of numerous small cysts grouped together in a honeycomb appearance, whereas the less common oligo- or macrocystic variant appears as a solitary cyst that is difficult to distinguish from pseudocysts, MCNs, or unifocal BD-IPMNs.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “SCAs frequently affect older women, with 75% to 85% female predominance, and an average age at presentation ranging from mid-50s to mid-60s. Approximately one-half to two-thirds of patients present with symptoms, most commonly abdominal pain, less commonly a palpable abdominal mass or jaundice. SCAs occur sporadically or, in approximately 2% of cases, in the setting of von Hippel-Lindau (VHL) disease, an autosomal dominant genetic disease arising from germline loss of the VHL tumor suppressor gene. .”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Unlike mucinous neoplasms, such as IPMNs or MCNs, serous cystic neoplasms have an extremely low risk of malignancy, with fewer than 1% of cases in the literature designated as invasive serous cystadenocarcinomas. Management has, therefore, moved away from unconditional operation to serial surveillance for asymptomatic lesions.4 Compared with smaller SCAs less then 4 cm in diameter, however, larger SCAs are 3-fold more likely to cause symptoms and, in 1 series, demonstrated a significantly faster growth rate of 2 cm versus 0.1 cm per year..”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “CPENs have an equal gender distribution and present at an average age of 50 to 60 years. Although older case series noted symptoms in a majority of patients, more recent studies suggest that most CPENs now present incidentally. More so than solid PNETs, a majority (greater than 80%) of CPENs are nonfunctioning (ie, without clinical manifestation of hormone overproduction).”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “IPMNs have an equal gender distribution and present at a median age of 65 to 67 years. Based on case series dating from the 1980s onward, a majority of patients with IPMN (60%–88%) present with symptoms, most often abdominal pain and, less frequently, weight loss, obstructive jaundice, or pancreatitis.Jaundice, in particular, occurs more frequently in patients with invasive versus noninvasive disease. More recently, however, IPMNs, in particular BD-IPMNs, are increasingly presenting as incidental radiologic findings.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “On either MRCP or CT, MD-IPMNs appear as a cystic and tortuous dilatation of the main pancreatic duct, with two-thirds of cases involving the head of the pancreas, 8% involving the entire duct, and a variable appearance of the associated pancreatic parenchyma, ranging from atrophic to enlarged and inflamed. BD-IPMNs, on the other hand, appear as solitary or multifocal cysts that communicate with the pancreatic ductal system but do not involve the main duct (ie, are associated with a normal-sized pancreatic duct).”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “ MD-IPMNs more frequently harbor malignancy than BD-IPMNs, with approximately 43% of MD-IPMNs containing invasive carcinoma at the time of resection and an additional 19% harboring high-grade dysplasia (synonymous with carcinoma in situ). Current consensus guidelines from the 2010 meeting of the International Association of Pancreatology, therefore, recommend surgical resection for all MD-IPMNs, as determined radiologically by either main pancreatic duct dilatation of 10 mm or greater on CT or MRI or borderline ductal dilatation of 5 to 9 mm with subsequent EUS confirmation of main duct involvement (ie, thickened walls or intraductal mucin or nodules).”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “Cyst size may be a weaker predictor of malignancy than other radiologic features, such as mural nodules,so it is allowable within the 2012 Fukuoka guidelines to observe BD-IPMNs larger than 3 cm, as long as no other high-risk or worrisome features are present and close surveillance with alternating EUS and MRCP is maintained every 3 to 6 months.”
Diagnosis and Management of Pancreatic Cystic Neoplasms
        Kim TS, Fernandez-del Castillo C
Hematology/Oncology Clin North America
Volume 29, Issue 4, August 2015, Pages 655–674
  • “In this outpatient population, the prevalence of unsuspected pancreatic cysts identified on 16-MDCT was 2.6%. Cyst presence strongly correlated with increasing age and the Asian race.” 
Prevalence of Unsuspected Pancreatic Cysts on MDCT
Laffan TA, Horton KM, Fishman EK, Hruban RH 
AJR 2008;802-807
  • “In our population, the prevalence of incidental pancreatic cyst discovered on EUS was 9.4% and the majority were less than 1 cm. Increasing age and female sex were associated with the development of pancreatic cysts.”


    Prospective Cross-Sectional Study of the Prevalence of Incidental Pancreatic Cysts During Routine Outpatient Endoscopic Ultrasound
Sey, Michael Sai Lai  et al.
Pancreas (in press)
  • “Pancreatic serous cystadenomas were most commonly found in the tail (39%). The mean (SD) axial dimension was 4.5 (2.7) cm. A total of 36% contained internal calcifications. Dilatation of the main pancreatic duct (14%) and pancreatic parenchymal atrophy (11%) were uncommon. The mean (SD) attenuation of components with the highest attenuation was 49.1 (35.0) Hounsfield units on the arterial phase and 48.5 (33.4) Hounsfield units on the portal venous phase. Only 20% of neoplasms demonstrated "classic" morphology, as defined by multiple thin nonenhancing septations, calcifications, as well as the absence of main pancreatic duct dilatation and vascular involvement.”
     Characterization of pancreatic serous cystadenoma on dual-phase multidetector computed tomography.
    Chu LC1, Singhi AD, Hruban RH, Fishman EK.
    J Comput Assist Tomogr. 2014 Mar-Apr;38(2):258-63
  • “ Pancreatic serous cystadenomas were most commonly found in the tail (39%). The mean (SD) axial dimension was 4.5 (2.7) cm. A total of 36% contained internal calcifications. Dilatation of the main pancreatic duct (14%) and pancreatic parenchymal atrophy (11%) were uncommon. The mean (SD) attenuation of components with the highest attenuation was 49.1 (35.0) Hounsfield units on the arterial phase and 48.5 (33.4) Hounsfield units on the portal venous phase.”
     Characterization of pancreatic serous cystadenoma on dual-phase multidetector computed tomography.
    Chu LC1, Singhi AD, Hruban RH, Fishman EK.
    J Comput Assist Tomogr. 2014 Mar-Apr;38(2):258-63
  • “ Only 20% of surgically resected serous cystadenomas fulfilled classic morphology. Attenuation was helpful in differentiating serous cystadenomas from insulinomas and other cystic pancreatic masses, but it was not helpful in differentiation from pancreatic adenocarcinomas. Morphologic features were more helpful in differentiating serous cystadenomas from malignant masses.”
     Characterization of pancreatic serous cystadenoma on dual-phase multidetector computed tomography.
    Chu LC1, Singhi AD, Hruban RH, Fishman EK.
    J Comput Assist Tomogr. 2014 Mar-Apr;38(2):258-63
  • “ The most common pancreatic abnormality found on imaging studies is fatty replacement of the pancreas, but calcifications and cysts may also be found. True epithelium lined cysts probably develop as a result of inspissated mucin that obstructs pancreatic ducts.”
    Cystic Lesions of the Pancreas
    Demos TC et al.
    AJR 179, December 2002;1375-1388
  • “ Cysts can be single or multiple. Most are microscopic, but infrequently cysts up to several centimeters in diameter are shown on imaging studies. Rarely cysts are so numerous and large that most of the pancreas is replaced. This phenomenon has been termed “Cytosis” and should not be mistaken for a cystic neoplasm.”
    Cystic Lesions of the Pancreas
    Demos TC et al.
    AJR 179, December 2002;1375-1388
  • “ The guidelines are as follows: Annual imaging surveillance is generally sufficient for benign serous cystadenomas smaller than 4 cm and for asymptomatic lesions. Asymptomatic thin-walled unilocular cystic lesions smaller than 3 cm or side-branch intraductal papillary mucinous neoplasms should be followed with CT or MRI at 6 and 12 months interval after detection.”
    Diagnosis and Management of Cystic Pancreatic Lesions
    Sahani DV et al.
    AJR 2013; 200:343-354
  • “ Cystic lesions with more complex features or with growth rates greater than 1cm/year should be followed more closely or recommended for resection if the patients condition allows surgery. Symptomatic cystic lesions, neoplasms with high malignant potential, and lesions larger than 3 cm should be referred for surgical evaluation. Endoscopic ultrasound with fine needle aspiration (FNA) biopsy can be used preoperatively to assess the risk of malignancy.”
    Diagnosis and Management of Cystic Pancreatic Lesions
    Sahani DV et al.
    AJR 2013; 200:343-354
  • Cystic Pancreatic Lesions: Nonneoplastic Lesions
    - Pseudocysts
    - Serous cystadenoma
    - Intraductal papillary mucinous neoplasms (IPMN)
    - Mucinous cystic neoplasms (MCN)
    - Disclaimer: IPMNs and MCNs have malignant potential
  • Cystic Pancreatic Lesions: Neoplastic Lesions
    - Solid pseudopapillary neoplasms (Hamoudi tumor)
    - Cystic pancreatic neuroendocrine tumor
    - Cystic degeneration of other solid pancreatic neoplasms
    - Lymphoepithelial cyst
    - Cystic adenocarcinoma of the pancreas
  • Cystic Pancreatic Lesions: Neoplastic Lesions
    Key CT findings
    - Solid nodules
    - Thick septations
    - Cyst wall thickening
    - Cyst wall enhancement
  • Cystic Pancreatic Lesions: Imaging Protocols
    - MDCT
    - MRI and MRCP
    - PET/CT
    - Endoscopic ultrasound
  • “ The major limitations of PET/CT in the evaluation of pancreatic cystic lesions include higher cost, false negative results for borderline and in-situ tumors, and false positive uptake in areas of lesion associated pancreatitis and post biopsy changes. Therefore, there are not enough data to justify a role of PET/CT in the characterization of cystic pancreatic lesions.”
    Diagnosis and Management of Cystic Pancreatic Lesions
    Sahani DV et al.
    AJR 2013; 200:343-354
  • “ Accordingly it would be prudent to perform followup evaluations every 2 years for side branch IPMNs smaller than 2 cm and to perform annual evaluations for IPMNs measuring 2-3 cm.”
    Diagnosis and Management of Cystic Pancreatic Lesions
    Sahani DV et al.
    AJR 2013; 200:343-354
  • 19.8% of Patients had a Pancreatic Cyst Incidentally Discovered
    “ The prevalence of pancreatic cysts at single shot fast SE MR imaging-especially cysts with a diameter smaller than 10mm is similar to that of pancreatic cysts at autopsy and higher than that of pancreatic cysts at transabdominal ultrasonography.”
    Pancreatic Cysts: depiction on single-shot fast spin echo MR images
    Zhang XM et al.
    Radiology 2002; May 223(2):547-53
  • Pancreatic Pseudocyst
    Peripancreatic fluid collection
    with well defined wall
    greater than or equal to 4 weeks after symptom onset
    Well-defined wall of fibrosis or granulation tissue
    10-20% of patients
    50% resolve spontaneously
    25% result in pain and infection
  • Pancreatic Pseudocyst
    Most common locations:
    - Lesser sac
    - Left anterior pararenal space
    - Right anterior pararenal space
    - Can track almost anywhere . . .
  • Pseudocyst Management
    1. Conservative management
    2. Drainage needed if:
    - Infected
    - Symptoms due to mass effect
    --- Bowel obstruction
    --- Biliary obstruction
    --- Intractable pain
    3. If there is persistent communication of pseudocyst with PD, drainage can continue indefinitely
    - Surgical or endoscopic internal drainage may be needed
  • Pseudocyst Drainage Options
    1. Percutaneous image-guided
    2. Surgical
    - Transgastric cyst-gastrostomy
    - Transduodenal cyst-duodenostomy
    - Cyst-jejunostomy to Roux-en-Y limb
    - Most common drainage route is to stomach
    3. Endoscopic route to stomach or duodenum
  • Pancreatic Abscess
    - Don’t use this term any more!
    - Not included in the latest Atlanta classification
    - Imprecise term which could apply to any of the previously mentioned terms
  • Venous Thrombosis
    1. Splenic vein thrombosis
    - Intimal injury secondary to adjacent inflammation
    - Mass effect and compression of vein
    2. SMV and portal vein thrombosis less common
    3. Look for varices (omental and gastroepiploic)
  • Pseudoaneurysms
    1. Pancreatic enzymes weaken arterial wall
    2. Most common sites:
    - Splenic artery (40%)
    - GDA (30%)
    - Pancreaticoduodenal (20%)
    - Gastric (5%), Hepatic (2%)
    3. Arterial phase is crucial
    4. Mortality is > 90% if the pseudoaneurysm rupture
  • Imaging Cystic Pancreatic Lesions: Options
    - CT
    - MRI
    - Ultrasound
    - PET/CT
    - EUS (endoscopic ultrasound)
  • “ This article reviews pathophysiology, prevalence, significance and recommendations for management of the various pancreatic cystic lesions. A better understanding of the variety of incidentally detected pancreatic cystic lesions can help direct appropriate management.”
    Incidentally detected cystic lesions of the pancreas on CT: review of literature and management suggestions
    Zaheer A, Pokharel SS, Wolfgang C, Fishman EK, Horton KM
    Abdom Imaging (2012) in press
  • Common Cystic Pancreatic Lesions
    - Pseudocyst (pancreatitis)
    - Serous cystadenoma
    - Mucinous cystic neoplasm (MCN)
  • IPMN (Intraductal Papillary Mucinous Neoplasm): Facts
    - Usually occurs in older population (7th decade) and a bit more common in men
    - Key is pancreatic duct involvement and classified as main duct, side branch and mixed type
    - Main pancreatic duct of ≥ 1 cm is suggestive of a main duct IPMN
    - Main pancreatic duct IPMN has higher incidence of malignancy and usually requires surgery
    - IPMN
  • Serous Cystadenoma: Classic Appearance
    -Multiple cysts with thin septations. Central scar with central calcification is classic.
    - Less common appearance is oligocystic variety (10%) with single cyst and hard to distinguish from MCN
    - Cysts contain glycogen but no mucin
    - Patients average age is 68 at time of dx and more common in woman
  • Mucinous Cystic Neoplasm of the Pancreas (MCN)
    - Occurs in the 4th -5th decade of life and almost exclusively in females
    - Usually in body or tail of pancreas
    - No communication with the pancreatic duct (unlike IPMN) but can obstrcut the pancreatic duct
    - Cysts in MCN are usually over 2 cm in size and less than 6 cysts present
    - Contains ovarian type stroma
  • IPMN (Intraductal Papillary Mucinous Neoplasm): Facts
    - Usually occurs in older population (7th decade) and a bit more common in men
    - Key is pancreatic duct involvement and classified as main duct, side branch and mixed type
    - Main pancreatic duct of ≥ 1 cm is suggestive of a main duct IPMN
    - Main pancreatic duct IPMN has higher incidence of malignancy and usually requires surgery
  • IPMN (Intraductal Papillary Mucinous Neoplasm): Facts
    Predictors of malignancy in IPMN include
    - Lesion size (≥ 3cm)
    - Interval growth over time (≥ 2mm/year)
    - Mural nodule(s)
    - Thick septations (enhancing)
    - Clinical symptoms (including abdominal pain and unexplained episodes of pancreatitis)
  • Cystic/Solid Tumors (solid tumors with cystic component)
    - Solid pseudopapillary tumors (SPEN)
    - Neuroendocrine tumors
    - Metastases to the pancreas
    - Adenocarcinoma (rarely)
    - Lymphoepithelial cyst
  • Patient Management
    1. Imaging followup with CT or MRI
    2. Endoscopic ultrasound (EUS)
    3. Surgery
    --Main duct IPMN
    -- MCN
    --Interval growth over 3-5 mm
  • Recommendations for radiologists confronted with an incidental pancreatic cyst
    - Surgery should be considered for patients with cysts larger than 3 cm.
    - If the lesion is a serous cystadenoma, surgery is deferred until the cyst is larger than 4 cm
    - Patients with simple cysts smaller than 3 cm can be followed up, but attempts should be made to characterize cysts larger than 2 cm at detection; if this cannot be done based on the available imaging study, MI is the preferred procedure
    - Cysts smaller than 1 cm cannot be further characterized by imaging, but can be followed up less frequently than cysts larger than 3 cm; in elderly patients (>80 years of age) hese cysts likely will not require further investigation
  • Recommendations for radiologists confronted with an incidental pancreatic cyst
    - Aspiration is strongly advised to exclude pseudocyst before any surgery is performed
    - Patients must remain asymptomatic during the follow-up period

    Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee
    Berland LL, Silverman SG, Gore RM et al.
    J Am Coll Radiol 2010;7(10):754-73
  • “ Serous cystadenoma of the pancreas have various distinguishing imaging features. Typically, a serous cystadenoma is morphologically classified as having either a polycystic, honeycomb, or oligocystic pattern.”
    Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings With Pathologic Correlation
    Choi JY et al.
    AJR 2009; 193:136-142
  • “ Serous cystadenoma of the pancreas have various distinguishing imaging features. Typically, a serous cystadenoma is morphologically classified as having either a polycystic, honeycomb, or oligocystic pattern. Atypical manifestations of serous cystadenoma can include giant tumors with ductal dilatation, intramural hemorrhages, solid variants, unilocular cystic tumors,interval growth and a disseminated form.”
    Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings With Pathologic Correlation
    Choi JY et al.
    AJR 2009; 193:136-142
  • “Atypical manifestations of serous cystadenoma can include giant tumors with ductal dilatation, intramural hemorrhages, solid variants, unilocular cystic tumors,interval growth and a disseminated form.”
    Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings With Pathologic Correlation
    Choi JY et al.
    AJR 2009; 193:136-142
  • Serous Cystadenoma of the Pancreas: Types
    - Polycystic
    - Honeycomb
    - Oligocystic
  • Serous Cystadenoma of the Pancreas: Facts
    - Serous cystadenomas can grow over time
    - More common in VHL disease
    - More common in the pancreatic head
  • Serous Cystadenoma of the Pancreas: Typical CT Findings
    - Polycystic pattern is most common in 70% of cases and cysts measure 2 cm or smaller
    - Central scar that calcifies is not uncommon
  • Serous Cystadenoma of the Pancreas: Typical CT Findings
    - Honeycomb pattern is second most common in 20% of cases and numerous cysts under a cm in size
    - Numerous cysts can typically not be seperated individually
  • Serous Cystadenoma of the Pancreas: Typical CT Findings
    - Oligocystic is least common in fewer than 10% of cases and a few cysts over 2 cm in size
    - Commonly called macrocystic cystadenoma and can be confused with mucinous cystic tumors
  • Serous Cystadenoma of the Pancreas: Atypical CT Findings
    - Giant serous cystadenoma (over 10 cm)
    - Serous cystadenoma with intratumoral hemorrhage
    - Solid serous cystadenoma
    - Unilocular cystic serous cystadenoma with calcification
    - Multifocal serous cystadenoma (disseminated form)
  • Cystic Pancreatic Lesions with Solid Components: Differential Dx
    -Mucinous cystic neoplasm (MCN)
    -IPMN
    -Solid and papillary epithelial neoplasm (SPEN)
    -Solid tumors with cystic degeneration (adenocarcinoma, islet cell tumor)

    Cystic Lesions of the Pancreas
    Khan A, Khosa F, Eisenberg RL
    AJR 2011;196:1244-1245
  • Unilocular Cystic Pancreatic Lesions: Differential Dx
    -Pancreatic pseudocyst
    -Intraductal papillary mucinous neoplasm (IPMN)
    -Mucinous cystadenoma
    -Oligoystic serous cystadenoma
    -Lymphoepithelial cyst
    -Cystic islet cell tumor
  • “ Multivariate analysis showed that tumor diameter and location of tumor in pancreatic head were independently associated with aggressive behavior.”
    Tumor Size and Location Correlate With Behavior of Pancreatic Serous Cystic Neoplasms
    Khashab MA, Shin EJ, Amateau, Canto MI, Hruban RH, Fishman EK, Cameron JC et al.
    AM J Gastroenterol 2011; 106:1521-1526
  • “ Preoperative CT was suggestive of SCN diagnosis in about a quarter of patients. Only tumor location in HOP were independently associated with the presence of symptoms.”
    Tumor Size and Location Correlate With Behavior of Pancreatic Serous Cystic Neoplasms
    Khashab MA, Shin EJ, Amateau, Canto MI, Hruban RH, Fishman EK, Cameron JC et al.
    AM J Gastroenterol 2011; 106:1521-1526
  • “A clinically significant proportion of (5.1%) of all SCNs were locally aggressive.Large tumor size and tumor location in the HOP were independent predictors of locally aggressive behavior in patients undergoing resection: however, small tumors of the HOP are rarely aggressive.”
    Tumor Size and Location Correlate With Behavior of Pancreatic Serous Cystic Neoplasms
    Khashab MA, Shin EJ, Amateau, Canto MI, Hruban RH, Fishman EK, Cameron JC et al.
    AM J Gastroenterol 2011; 106:1521-1526
  • “Preoperative CT was suggestive of SCN diagnosis in about a quarter of patients. Only tumor location in HOP were independently associated with the presence of symptomsA clinically significant proportion of (5.1%) of all SCNs were locally aggressive.Large tumor size and tumor location in the HOP were independent predictors of locally aggressive behavior in patients undergoing resection: however, small tumors of the HOP are rarely aggressive.”
    Tumor Size and Location Correlate With Behavior of Pancreatic Serous Cystic Neoplasms
    Khashab MA, Shin EJ, Amateau, Canto MI, Hruban RH, Fishman EK, Cameron JC et al.
    AM J Gastroenterol 2011; 106:1521-1526
  • Serous Cystadenoma of the Pancreas: Atypical CT Findings
    - Giant serous cystadenoma (over 10 cm)
    - Serous cystadenoma with intratumoral hemorrhage
    - Solid serous cystadenoma
    - Unilocular cystic serous cystadenoma with calcification
    - Multifocal serous cystadenoma (disseminated form)
  • Serous Cystadenoma of the Pancreas: Typical CT Findings
    - Polycystic pattern is most common in 70% of cases and cysts measure 2 cm or smaller
    - Central scar that calcifies is not uncommon
    - Honeycomb pattern is second most common in 20% of cases and numerous cysts under a cm in size
    - Numerous cysts can typically not be seperated individually

    - Oligocystic is least common in fewer than 10% of cases and a few cysts over 2 cm in size
    - Commonly called macrocystic cystadenoma and can be confused with mucinous cystic tumors
  • Serous Cystadenoma of the Pancreas: Facts
    - Serous cystadenomas can grow over time
    - More common in VHL disease
    - More common in the pancreatic head
  • Serous Cystadenoma of the Pancreas: Types
    - Polycystic
    - Honeycomb
    - Oligocystic
  • "Atypical manifestations of serous cystadenoma can include giant tumors with ductal dilatation, intramural hemorrhages, solid variants, unilocular cystic tumors,interval growth and a disseminated form."

    Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings With Pathologic Correlation
    Choi JY et al.
    AJR 2009; 193:136-142

  • "Serous cystadenoma of the pancreas have various distinguishing imaging features. Typically, a serous cystadenoma is morphologically classified as having either a polycystic, honeycomb, or oligocystic pattern."

    Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings With Pathologic Correlation
    Choi JY et al.
    AJR 2009; 193:136-142

  • "Serous cystadenoma of the pancreas have various distinguishing imaging features. Typically, a serous cystadenoma is morphologically classified as having either a polycystic, honeycomb, or oligocystic pattern. Atypical manifestations of serous cystadenoma can include giant tumors with ductal dilatation, intramural hemorrhages, solid variants, unilocular cystic tumors,interval growth and a disseminated form."

    Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings With Pathologic Correlation
    Choi JY et al.
    AJR 2009; 193:136-142

  • "MDCT and MRI have a high accuracy in classifying cysts into mucinous and nonmucinous categories and perform similarly in estimating histologic aggressiveness."

    Comparitive Performance of MDCT and MRI with MR Cholangiopancreatography in Characterizing Small Pancreatic Cysts
    Sainani NI et al.
    AJR 2009; 193:722-731

  • "A dedicated thin-section dual phase technique improves the diagnostic performance of MDCT for assessing cyst morphology and should be the preferred approach for evaluating small cysts with CT, although MRI using MRCP can be resorted to in cases with doubtful or suspicious features or can be used alternatively instead of CT."

    Comparitive Performance of MDCT and MRI with MR Cholangiopancreatography in Characterizing Small Pancreatic Cysts
    Sainani NI et al.
    AJR 2009; 193:722-731

  • "MRI enables more confident assessment of the morphology of small cysts than MDCT, but the accuracy of the two imaging techniques for cyst characterization is comparable."

    Comparitive Performance of MDCT and MRI with MR Cholangiopancreatography in Characterizing Small Pancreatic Cysts Sainani NI et al. AJR 2009; 193:722-731

  • "MRI enables more confident assessment of the morphology of small cysts than MDCT, but the accuracy of the two imaging techniques for cyst characterization is comparable. MDCT and MRI have a high accuracy in classifying cysts into mucinous and nonmucinous categories and perform similarly in estimating histologic aggressiveness."

    Comparitive Performance of MDCT and MRI with MR Cholangiopancreatography in Characterizing Small Pancreatic Cysts
    Sainani NI et al.
    AJR 2009; 193:722-731

  • "With advancements in CT technology and improved spatial resolution, unsuspected small pancreatic cysts are being detected with increased frequency."

    Prevalence of Unsuspected Pancreatic Cysts on MDCT
    Laffan TA, Horton KM, Fishman EK, Hruban RH
    AJR 2008;802-807
  • "In this outpatient population, the prevalence of unsuspected pancreatic cysts identified on 16-MDCT was 2.6%. Cyst presence strongly correlated with increasing age and the Asian race."

    Prevalence of Unsuspected Pancreatic Cysts on MDCT
    Laffan TA, Horton KM, Fishman EK, Hruban RH
    AJR 2008;802-807
  • Serous Cystadenoma of the Pancreas: Facts

    - Usually solitary but can be multiple in VHL
    - Can appear solid on occasion
    - Usually cystic mass described as polycystic, honeycomb, and oligocystic.
    - 70% are polycystic in type
  • Serous Cystadenoma: CT Findings

    - Cystic lesion with collection of 2-6 cysts ranging in size from a few mm to 2 cm in size
    - Central scar with or without calcification occurs in 30% of cases and is a key differential dx point
    - Key differential dx is IMPN and mucinous cystic neoplasm
  • Serous Cystadenoma: CT Findings

    - Smooth lesion surface without lobulations, a thick enhancing wall and peripheral calcifications are more consistent with a mucinous cystic tumor
    - CT of Serous Cystadenoma of the Pancreas and Mimicking Masses Kim HJ et al. AJR 2008;190:406-412
  • Cystic Pancreatic Tumors: Differential Dx

    - Serous cystadenoma
    - Mucinous cystadenoma
    - Pseudopapillary tumor
    - Cystic islet cell tumor - IPMN
  • Pancreatic Lesions in Von Hippel-Lindau Disease

    - True cysts
    - Serous cystadenomas
    - Islet cell tumors
  • Cystic Pancreatic Lesion: Forming a Differential Dx

    - Clinical history
    - Lesion size
    - Lesion attenuation
    - Septations or calcification
    - Pancreatic duct size
    - Relationship of cystic lesion to pancreatic duct
  • Cystic Pancreatic Tumors: Features For Low Risk of Malignancy

    - Asymptomatic patient
    - Size under 3 cm
    - Main pancreatic duct under 6 mm
    - No solid component (mural nodule) within or associated with the cystic lesion
    - No evidence of adenopathy
    - No common bile duct dilatation
  • Microcystic adenoma II

    - Honeycomb or spongelike appearance. Septa have rich capillary network.
    - Glycogen rich.
    - Seen in von Hippel Lindau syndrome
    - Appearance may overlap with MCN.
  • Microcystic adenoma- Serous cystadenoma I

    - Second commonest cystic neoplasm but less common than MCN.
    - Benign, moderately vascular.
    - Older women with abdominal pain
    - Cluster of small cysts 2mm to 2cm. Larger cysts at periphery of lesion.
    - Fibrous septa that radiate from the center
    - Central stellate scar that may calcify
  • Pancreatic cystic lesions

    - Conservative followup.
    - 1. patient wishes conservative Rx
    - 2. patient asymptomatic with respect to the lesion.
    - 3. lesion < 3cm, no solid component
    - 4. main pancreatic duct <6mm.
  • Microcystic adenoma II

    - Honeycomb or spongelike appearance. Septa have rich capillary network.
    - Glycogen rich.
    - Seen in von Hippel Lindau syndrome
    - Appearance may overlap with MCN.
  • Microcystic adenoma- Serous cystadenoma I

    - Second commonest cystic neoplasm but less common than MCN.
    - Benign, moderately vascular.
    - Older women with abdominal pain
    - Cluster of small cysts 2mm to 2cm. Larger cysts at periphery of lesion.
    - Fibrous septa that radiate from the center
    - Central stellate scar that may calcify
  • Question #3 - Are there any endorsed criteria for conservative follow-up of a cystic pancreatic lesion?

    - Tanaka M et al. International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasms and Mucinous Cystic Neoplasms of the Pancreas. Pancreatology 2006; 6:17-32.
    - Consensus of the Working Group of the International Association of Pancreatology.
  • Cystic Neoplasms of the Pancreas: Differential Dx

    - Pancreatic pseudocyst
    - True pancreatic cyst
    - Serous cystadenoma
    - Mucinous cystadenoma/cystadenocarcinoma
    - IPMN
    - Solid Papillary Epithelial Neoplasm
  • Cystic Pancreatic Lesions: Differential Diagnosis

    - Pancreatic cyst (congenital or true cyst)
    - Pseudocyst (post pancreatitis)
    - Microcystic adenoma
    - Macrocystic (Mucinous) Cystic Tumor
    - Intraductal Papillary Mucinous Tumor (IPMN)
    - Islet cell tumors (especially non-functioning tumors)
    - Hamoudi tumor (solid papillary epithelial neoplasm)
  • Pancreatic cyst (congenital or true cyst): Facts

    - Usually multiple and commonly associated with diseases that involve other organs
    - Autosomal dominant polycystic kidney disease (5% of cases)
    - Von Hippel-Lindau disease (50-75% of cases)
    - Cystic fibrosis-single or numerous cysts
  • Pancreatic cyst (congenital or true cyst): Facts

    - May be solitary
    - True cyst
    - Lymphoepithelial cyst
  • Microcystic Adenoma: facts

    - Benign neoplasm
    - F > M by 2-1
    - Usually detected in 7th decade
    - Found in von Hippel-Lindau syndrome
    - Cysts usually under 2 cm. and may contain central stellate scar (often calcified)
    - Contains glycogen but no mucin
  • Macrocystic Serous Adenoma of the Pancreas

    - Benign lesion like classic microcystic serous adenoma but the septae are poorly visualized
    - May be impossible to distinguish from a macrocystic mucinous tumor
    - Macrocystic Serous Adenoma of the Pancreas: Radiologic-Pathologic Correlation
    Khurana B et al.
    AJR 2003;181:119-123
  • Mucinous Cystic Tumor: Facts

    - Malignant neoplasm also called Cystadenocarcinoma or Macrocystic Adenoma neoplasm
    - F > M by 9-1
    - Usually detected in 5th to 6th decade
    - Cysts often irregular and usually greater than 2 cm.
    - Contains mucin
  • Mucinous Cystic Tumor: Facts

    - May contain peripheral curvilinear cyst wall calcification
    - Can be difficult to distinguish from benign microcystic cystadenoma
  • Cystic Neoplasms of the Pancreas: WHO Classification 2000

    - Serous microcystic adenoma
    - Serous oligocystic adenoma
    - Serous cystadenocarcinoma
    - Mucinous cystadenoma
    - Mucinous cystic tumor-bordeline
    - Mucinous cystadenocarcinoma
    - Noninvasive
    - Invasive cont.
  • Cystic Neoplasms of the Pancreas: WHO Classification 2000

    - Intraductal papillary mucinous adenoma
    - Intraductal papillary mucinous neoplasm-borderline
    - Intraductal papillary mucinous carcinoma
    - Noninvasive
    - invasive
  • Macrocystic Serous Cystadenoma: CT Findings

    - Location in the pancreatic head
    - Lobulated contour
    - Thin wall
    - Absence of wall enhancement
    - If all three findings present specificity for dx is 100%
  • von Hippel-Lindau Disease: Pancreatic Pathology

    - Occur in up to 77% of patients
    - Lesions include
    - Simple pancreatic cysts
    - Serous cystadenomas
    - Neuroendocrine tumors
    - Pancreatic carcinoma
  • Cystic Pancreatic Mass: Differential Diagnosis

    - Pseudocyst
    - Serous cystadenoma
    - Mucinous cystic tumor
    - IMPN (intraductal mucinous tumor)
    - SPEN (solid and papillary neoplasm)
    - Cystic islet cell tumor
  • Serous Cystadenoma: Facts

    - AKA microcystic cystadenoma
    - Usually woman over age 60
    - Multiple 0.2-2.0 cm cysts
    - Central calcified stellate scar classic
    - May seem cystic or even solid on CT
  • Mucinous Cystic Tumor: Facts

    - Enhancing septations and nodules are common
    - Peripheral calcification is seen in up to 25% of cases
    - Malignant potential and should be removed
  • Multiple True Pancreatic Cysts: Differential Diagnosis

    - Von Hippel-Lindau disease
    - Beckwith-Wiedermann syndrome
    - Autosomal dominant PCK
    - Pancreas
    - Meckel-Gruber syndrome
  • Guidelines

    - 1. Asymptomatic cystic lesions without main duct dilatation [> 6 mm], those without mural nodules, and those < 30 mm in size have a low risk of progressing to invasive cancer in near-term [ 12 –to 36 month] followup.
    - 2. Yearly followup if lesion is <10 mm in size. 6-12 month follow-up for lesions 10-20 mm. 3-6 month followup for lesions >20 mm.
    - 3. Interval can be lengthened after 2 yrs of no change
    - 4. Appearance of sx attributable to the cyst [eg pancreatitis], presence of intramural nodules, cyst size > 30 mm, or dilatation of pancreatic duct >6mm are indications for resection.
  • - 1.Proliferation of mucinous epithelial cells lining pancreatic ducts- arranged in papillary patterns.
    - 2. Intraluminal accumulation of mucin and cystic dilatation of ducts.
    - 3. Spectrum of architectural atypia from benign to malignant.
  • IPMN

    - 4. 1/3 of cases associated with invasive carcinoma.
    - 5. Communicate with pancreatic duct, ( unlike MCN ).
    - 6. No ovarian stroma.
    - 7. Mucin may be seen pouring into duodenum from patulous orifice of pancreatic duct.
  • IPMN

    - 1. IPMN Adenoma
    - 2. IPMN Borderline
    - 3. IPMN Carcinoma in situ
    - 4. IPMN Invasive carcinoma
    - A. Colloid Carcinoma-Muc 2
    - B. Ductal Carcinoma- Muc 1
  • Conclusions from recent studies

    - Commonest small cysts are MCN, IPMN, and serous.
    - Very few pseudocysts in absense of pancreatitis.
    - Fewer than 5% of incidentally detected pancreatic cysts <2cm are malignant.
    - Patient’s choice: Follow, Bx under US, surgery.
    - General consensus:
    - 1. Under 2 cm observe.
    - 2. >2cm Young and middle-aged resect.
    - 3. >2cm older and less fit. Endoscopic US with fine needle aspiration, [ 40-50% sensitivity, 99+% specificity ]. Resect if mucin, high CEA, mucinous epithelium, malignant cells, or neuroendocrine cells.
  • The natural history of the incidentally discovered small simple pancreatic cyst; long term follow-up and clinical implications

    - Handrich SJ et al. AJR 2005; 184: 20-23. Mayo Clinic.
    - <2.0 cm cysts dx by sonography or CT 1985-1996.
    - 79 pts. 49 adequate follow-up.
    - 13 [ 59% ] no change or smaller. Mean size 8 mm, mean follow-up 9 years.
    - 9 [ 415 ] enlarged. Mean 14 mm to 26 mm. Mean follow-up 8 years. One pt operated on- pseudocyst.
    - 27 clinical follow-up or response to questionaire. Mean follow-up 10 years. None developed pancreatic disease.
    - 18 patients died. No suggestion of pancreatic disease.
    - 12 patients lost to follow-up.
  • Pancreatic cysts 3 cm or smaller: How aggressive should treatment be?

    - Sahani DV et al Radiology 2006; 238: 912-919. Mass General
    - 510 pts with cysts 1998-2004. 122 pancreatitis excld. 313/388 {80.6%} <3cm.
    - 86 patients in study with adequate data. Aged 24-89 years.
    - 48 surgery vs 38 non surgical.
    - 75 benign, 8 borderline malignant, 3 ca in situ.
    - Results of surgery: 37 benign MCN 13, IPMN side branch 14, serous 3, pseudocyst, cystic neuroendocrine 2, lymphoepithelial cyst 1, unclass 2 11 malignant
    - 8 borderline : 6 side-branch, 2 MCN. 3 ca in situ: 2 side-branch, 1 MCN.
    - 38 pts followed, all had US bx -1 later developed side-branch IMN with ca in situ.
  • Cystic pancreatic neoplasms- Observe or operate?

    - Spinnelli KS et al. Annals of Surgery 2004; 239: 651-659. U.Wisconsin. 1995-2002.
    - 290 cysts 1.2%. 132 hx pancreatitis thus, 168, 0.7% incidence of presumed neoplastic cysts.
    - 79 patients followed -16 months mean.
    - 15 increased in size [ 19% ]
    - 47 no change in size [ 59% ]
    - 17 decrease in size [ 22% ]
    - 49 had surgery
    - 14 benign 10 serous, 2 SPEN, 1 lymphoep, 1 simple cyst
    - 25 premalignant 16 MCN, 5 IPMn, 4 cystic neuroendocrine
    - 10 malignant 7 IPMN with Ca, 3 MCN
    - Recommend surgery if symptomatic, increasing, or fit older pts, since 60% of cysts in pts over 60 were malignant.
  • Intraductal Papillary Mucinous Tumor (IPMN): Facts

    - Equal frequency men and woman
    - Usually detected in 6th and 7th decade
    - Commonly associated with dilated pancreatic duct
    - Lesions may be multiple and variable in size
  • Intraductal Papillary Mucinous Tumor (IPMN): Facts

    - Initially referred to as mucin producing pancreatic neoplasms
    - May be incidental finding or patients present with pancreatitis like symptoms
    - Up to 60% occur in the head/uncinate process
  • Cystic Endocrine Tumors

    - Insulinomas
    - Gastrinomas
    - Glucagonomas
    - Non-functioning tumors
© 1999-2018 Elliot K. Fishman, MD, FACR. All rights reserved.