Imaging Pearls ❯ Pancreas ❯ Cystic Tumors of the Pancreas
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- Purpose: A wide array of benign and malignant lesions of the pancreas can be cystic and these cystic lesions can have overlapping imaging appearances. The purpose of this study is to compare the diagnostic accuracy of a radiomics-based pancreatic cyst classifier to an experienced academic radiologist.
Methods: In this IRB-approved retrospective single-institution study, patients with surgically resected pancreatic cysts who underwent preoperative abdominal CT from 2003 to 2016 were identified. Pancreatic cyst(s) and background pancreas were manually segmented, and 488 radiomics features were extracted. Random forest classification based on radiomics features, age, and gender was evaluated with fourfold cross-validation. An academic radiologist blinded to the final pathologic diagnosis reviewed each case and provided the most likely diagnosis.
Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists.
Chu LC, Park S, Soleimani S, Fouladi DF, Shayesteh S, He J, Javed AA, Wolfgang CL, Vogelstein B, Kinzler KW, Hruban RH, Afghani E, Lennon AM, Fishman EK, Kawamoto S.
Abdom Radiol (NY). 2022 Dec;47(12):4139-4150. - Results: 214 patients were included (64 intraductal papillary mucinous neoplasms, 33 mucinous cystic neoplasms, 60 serous cystadenomas, 24 solid pseudopapillary neoplasms, and 33 cystic neuroendocrine tumors). The radiomics-based machine learning approach showed AUC of 0.940 in pancreatic cyst classification, compared with AUC of 0.895 for the radiologist.
Conclusion: Radiomics-based machine learning achieved equivalent performance as an experienced academic radiologist in the classification of pancreatic cysts. The high diagnostic accuracy can potentially maximize the efficiency of healthcare utilization by maximizing detection of high-risk lesions.
Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists.
Chu LC, Park S, Soleimani S, Fouladi DF, Shayesteh S, He J, Javed AA, Wolfgang CL, Vogelstein B, Kinzler KW, Hruban RH, Afghani E, Lennon AM, Fishman EK, Kawamoto S.
Abdom Radiol (NY). 2022 Dec;47(12):4139-4150. - “This study showed that a radiomics-based model can achieve equivalent performance as an experienced academic radiologist in the classifcation of a wide array of pancreatic cysts with variable malignant potential. This model has the potential to refne pancreatic cyst management by improving diagnostic accuracy of cystic lesions, which can minimize healthcare utilization while maximizing detection of malignant lesions. This study confrms the ability of a radiomicbased model to accurately classify pancreatic cystic neoplasms. Further validation and clinical integration of this model could help optimize management of pancreatic cysts by maximizing the rate of detection of malignant lesions while reducing healthcare utilization.”
Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists.
Chu LC, Park S, Soleimani S, Fouladi DF, Shayesteh S, He J, Javed AA, Wolfgang CL, Vogelstein B, Kinzler KW, Hruban RH, Afghani E, Lennon AM, Fishman EK, Kawamoto S.
Abdom Radiol (NY). 2022 Dec;47(12):4139-4150. 
Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists.
Chu LC, Park S, Soleimani S, Fouladi DF, Shayesteh S, He J, Javed AA, Wolfgang CL, Vogelstein B, Kinzler KW, Hruban RH, Afghani E, Lennon AM, Fishman EK, Kawamoto S.
Abdom Radiol (NY). 2022 Dec;47(12):4139-4150.
- In general, all suspected MCNs exceeding 4 cm in size and any suspected MCN which has a mural nodule or is symptomatic should undergo resection. Surveillance can be pursued for presumed MCNs less than 3 cm in size in the absence of WFs or HRS that characterize indications for resection in IPMN disease. In 3- to 4-cm lesions suspected to be MCN, the risks of empiric resection with a low likelihood of finding invasive disease should be balanced with the need for long-term surveillance. As the natural history of MCN growth is not well understood, adherence to a surveillance regimen is important; this can be quite prolonged as a diagnosis typically occurs in the fourth or fifth decade of life.
Surveillance of Pancreatic Cystic Neoplasms
Ankit Chhoda, Julie Schmidt, James J. Farrell
Gastrointest Endoscopy Clin N Am 33 (2023) 613–640
- Cystic Pancreatic Tumors
- IPMN (Intraductal papillary Mucinous neoplasm)
- MCN (Mucinous Cystic Neoplasm)
- SCN (Serous Cystadenoma)
- cystic neuroendocrine neoplasm (PNET)
- solid-pseudopapillary neoplasm (SPEN)
- acinar-cell cystic neoplasm
- ductal adenocarcinoma with cystic degeneration - Serous Cystadenoma: Facts
- one-third of pancreatic cystic neoplasms
- almost always benign
- occur more commonly in women
- usually present between the 5th and 7th decade of life (mean age 62 years)
- More common in patients with VHL - Serous Cystadenoma: Facts
- Microcystic (multiple cysts under 2cm with septa and a honeycomb appearance)
- Macrocystic (multiple cysts over 2cm)
- mixed microcystic and macrocystic (mix of cysts over and under 2cm)
- Solid (often enhancing and looking like PNET) - Serous Cystadenoma: CT Findings
- Calcifications in up to 30% of cases
- Patterns of calcifications are variable
- More common in body and tail of pancreas
- Classic cases are easy to diagnosis but many cases are atypical - Serous Cystadenoma: Pathology Findings
Serous cystadenoma shows low viscosity, low amylase level, and low CEA levels (<5 to 20 ng/mL), with variable levels of pancreatic enzymes such as Amylase isoenzymes and CA-125. Cancer antigen (CA 72-4) level is low as well. - Serous Cystadenoma: Differential Diagnosis
- IPMN (Intraductal papillary Mucinous neoplasm)
- MCN (Mucinous Cystic Neoplasm)
- SCN (Serous Cystadenoma)
- cystic neuroendocrine neoplasm (PNET)
- solid-pseudopapillary neoplasm (SPEN)
- acinar-cell cystic neoplasm
- ductal adenocarcinoma with cystic degeneration
- Lymphoepithelial cyst - “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,Volume 98, Issue 3,2017, Pages 191-202 
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,Volume 98, Issue 3,2017, Pages 191-202- ”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.”
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,Volume 98, Issue 3,2017, Pages 191-202 - “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.”
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,Volume 98, Issue 3,2017, Pages 191-202 - “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. This pattern could be easily misdiagnosed as neuroendocrine tumor of the pancreas, or other solid pancreatic neoplasms.”
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,Volume 98, Issue 3,2017, Pages 191-202 
- Squamoid Cyst of Pancreatic Ducts This is a recently recognized type of cystic lesion in the pancreas, in which cystically dilated ducts are lined by a squamous/transitional epithelium without keratinization. The larger and clinically manifested examples reported were unilocular. The cells in the basal/parabasal region express p63 (transitional/squamous cell marker, not detected in any normal pancreas or nonsquamous neoplasia). The superficial cells are positive for MUC1 and MUC6 (markers present in intercalated duct cells), and negative for GLUT-1 (consistent marker of serous adenomas, another tumor of presumed centroacinar cell origin). These cystic lesions are believed to be the larger versions of a relatively common incidental change in the acinar lobules. These microscopic lesions have abortive septae, irregular contours, are found lying within compact acinar tissue, and appear to be transforming from intercalated ducts, often showing adjacent tightly packed clusters of ducts with similar morphology. The cysts typically contain distinctive acidophilic acinar secretions that form concretions , more evident in medium-sized examples, confirming their communication with the acinar system, and suggesting a localized obstruction in their pathogenesis.
Cystic lesions of the pancreas. Volkan Adsay, N.
Mod Pathol 20 (Suppl 1), S71–S93 (2007). - All these cystic lesions of the pancreas are thought to be benign. Clinically, it is important to distinguish SCOPs from mucinous cyst-forming neoplasms, such as MCNs or IPMNs. In contrast to SCOPs, these mucinous lesions carry the risk of malignant transformation and have potential to progress to invasive adenocarcinoma. However, the differential diagnosis of pancreatic cystic lesions is difficult because the radiologic and clinical findings are not characteristic. IPMNs are characterized by cystic dilatation of pancreatic ducts in which intraductal proliferation of neoplastic mucin-producing cells is usually arranged in a papillary pattern. MCNs are characterized by an ovarian-type stroma that forms a layer of variable thickness beneath the epithelial lining. These neoplasms are composed of large multilocular cysts of size 1 cm or greater. The cysts have thick fibrous walls, and they do not visibly communicate with the main pancreatic duct.2 Like in almost all patients in the reported cases of SCOPs in the literature, the case in this study was also radiologically diagnosed with MCN and it was decided to perform surgical resection.
Squamoid cyst of pancreatic ducts: A case report.
Park JI.
Ann Hepatobiliary Pancreat Surg. 2021 May 31;25(2):293-298 - “In conclusion, the term SCOP has been proposed recently, and it is a very rare benign lesion. With the improvement in imaging techniques, SCOPs are being increasingly recognized and should be considered in the differential diagnoses of pancreatic cystic lesions. As shown in the literature, SCOPs are often indistinguishable from cystic neoplasms of the pancreas preoperatively; most cases of SCOPs are confirmed after surgical resection in order to exclude malignancy. Identification of the squamous epithelium in cytological samples through EUS guided FNA may help avoid unnecessary extended resections. SCOP remains a difficult diagnosis to establish preoperatively, and further studies are needed to identify specific preoperative characteristics that can accurately differentiate this lesion.”
Squamoid cyst of pancreatic ducts: A case report.
Park JI.
Ann Hepatobiliary Pancreat Surg. 2021 May 31;25(2):293-298
- PancreaSeq® Genomic Classifier
- PancreaSeq GC test is DNA and mRNA next-generation sequencing analysis of 74 genes. The method allows to detect single nucleotide variants (SNVs), insertions and deletions (indels) in 20 genes related to pancreatic cysts and pancreatic cancer, including KRAS and GNAS, loss of heterozygosity (LOH) analysis and copy number alterations (CNAs) at 13 chromosomal regions, including the RNF43, SMAD4, TP53, PTEN, VHL, and NF2 tumor suppressor genes. In addition, it detects >150 types of gene fusions involving the ALK, BRAF, FGFR2, NTRK1, NTRK3, RET, ROS1, RAF1, PRKCA, PRKCB genes and expression of specific genetic markers, including KRT7, KRT20, CHRGR, and PGK1. Finally, it detects expression of the CEA (CECAM5) gene by qRT-PCR. The test is using a small amount of nucleic acids (DNA and RNA) isolated from pancreatic cyst fluid collected into preservative solution during ultrasound-fine needle aspiration (EUS-FNA) procedure. The findings are subjected to algorithmic analysis to categorize as Negative or Positive for specific alterations associated with different cyst types and risk of progression.
- IPMNs and MCNs are precursor neoplasms to pancreatic ductal adenocarcinoma; however, only a subset harbor or progress to malignancy. Studies have shown that IPMNs and MCNs with genetic alterations in TP53, SMAD4 and the phosphatidyl-3 kinase (PI3K) pathway, which include PIK3CA, PTEN, and AKT1, are associated with high-grade dysplasia and early invasive pancreatic ductal adenocarcinoma (advanced neoplasia). Kanda et al detected TP53 mutations in 56% of IPMNs with advanced neoplasia.(10) Similarly, 40% to 60% of IPMNs with advanced neoplasia harbor alterations in PIK3CA, PTEN, AKT1 and SMAD4.(11-13) Using EUS-FNA obtained pancreatic cyst fluid, Singhi et al found 88% of IPMNs with advanced neoplasia have mutations in KRAS and/or GNAS with concurrent alterations in TP53, PIK3CA, PTEN or AKT1.(1-2)
- DISCLAIMER PancreaSeq GC is a diagnostic test that was developed and its performance characteristics determined by the UPMC Molecular and Genomic Pathology laboratory. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research only. This laboratory is certified under the Clinical Laboratory Improvement Amendments (CLIA) as qualified to perform high complexity clinical laboratory testing. PancreaSeq test does not sequence genes in their entirety and mutations outside of mutation hotspots, some insertions and deletions may not be detected. This test does not provide information on germline or somatic status of detected mutations. Certain sample characteristics may result in reduced sensitivity, including low sample cellularity.
- “Mucinous cystic neoplasms (MCN) of the pancreas are cystic tumors with malignant potential.These uncommon lesions predominantly occur in middle-aged women and are usually located in the body or tail of the pancreas. Ovarian stroma is the pathologic hallmark of MCN and differentiates them from intraductal papillary mucinous neoplasms (IPMN). Mucinous cystic neoplasms are typically less likely to harbor high-grade dysplasia or invasive carcinoma (HGD/IC) compared with other cystic neoplasms of the pancreas, such as main-duct or branch-duct IPMN.”
Identification of high-risk features in mucinous cystic neoplasms of the pancreas
Maximiliano Servin-Rojas et al.
Surgery (2023) in press - “ Tumors with a size 4 cm and/or a high CA 19-9 level should be considered for prompt surgical resection. Conversely, tumors <4 cm with no other high-risk features have a negligible risk for high-grade dysplasia or invasive carcinoma and may benefit from nonoperative surveillance. Mural nodularity is an additional suspicious feature. These findings may contribute to future guidelines.”
Identification of high-risk features in mucinous cystic neoplasms of the pancreas
Maximiliano Servin-Rojas et al.
Surgery (2023) in pres
- “ PCLs are broadly classified into mucinous or nonmucinous lesions. Mucinous PCLs have a propensity for malignant transformation and include main duct intraductal papillary mucinous neoplasms (MD-IPMNs), branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), and mucinous cystic neoplasms (MCNs).Among nonmucinous cysts, cystic neuroendocrine tumors and solid pseudopapillary neoplasms can progress to malignancy, whereas serous cystadenomas have a less than 1% probability of malignancy, and pseudocysts are benign inflammatory cysts. Among neoplastic PCLs, IPMNs are the most common lesions encountered in clinical practice.
Comparison of Society Guidelines for the Management and Surveillance of Pancreatic Cysts: A Review
Hassan Aziz et al.
JAMA Surg. 2022;157(8):723-730. - “All guidelines that graded the quality of evidence defined it as low to very low quality. As such, it is difficult to interpret what truly are worrisome or high-risk PCL features. Future studies shouldmore accurately define cyst features as they pertain to the risk of occult malignancy or malignant transformation. In addition, as the natural history of PCLs varies considerably by PCL subtype, future studies need to delineate PCL subtype-specific recommendations. The European and IAP/Fukuoka guidelines addressed this, in part, as these recommendations provided PCL subtype-specific recommendations and stratified concerning features by type of cyst. The evolution of advanced diagnostic tools, such as cyst fluid next generation sequencing and EUS-guided needle-based confocal laser endomicroscopy, may augment current algorithms to specify cyst type and define malignancy potential based on cyst-specific information rather than more general imaging or EUS-based high-risk features.”
Comparison of Society Guidelines for the Management and Surveillance of Pancreatic Cysts: A Review
Hassan Aziz et al.
JAMA Surg. 2022;157(8):723-730. - “Owing to the low-quality evidence on which many guidelines are based and the inherent morbidity of pancreatic surgery, it is imperative that patients with PCLs are referred to institutions with advanced diagnostics and a multidisciplinary approach to patient surveillance and management.”
Comparison of Society Guidelines for the Management and Surveillance of Pancreatic Cysts: A Review
Hassan Aziz et al.
JAMA Surg. 2022;157(8):723-730.
- Cystic Pancreas Lesions: Mimics
- Solid and Pseudopapillary Epithelial Neoplasms
- Cystic Features of Pancreatic Ductal Adenocarcinoma
- Cystic Neuroendocrine Tumor - "SCNs typically are described as having a honey- comb or multilocular appearance with or without a central scar. However, there can be variations in the morphologic appearance with polycystic, oligocystic, and solid patterns described. Microcystic morphology is more common in SCNs. The classic imaging features are a lobulated external contour and central scar with stellate calcification. SCNs rarely demonstrate peripheral enhancing capsule or mural nodules.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “Lymphoepithelial cysts are rare cysts lined with squamous epithelium and surrounded by lymphoid tissue. They typically affect men who are middle-aged or older and are exophytic with a higher CT attenuation compared with SCNs and MCNs. The reference standard for diagnosis is excision.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “IPMNs are cystic neoplasms with variable degree of malignant potential. They may evolve into dysplasia or invasive carcinoma and are associated with a higher risk for the development of PDAC in the gland separate from the IPMN sites. The rate of progression increases with time. Low-risk IPMNs have an approximately 8% chance of progression, whereas higher risk IPMNs have an approximately 25% chance of progression to PDAC in 10 years. Even presumed low- risk BD-IPMNs may demonstrate growth after 5 years.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "MCN occur almost exclusively in women and more commonly are found in the pancreatic tail. MCNs are oval or round and can show septations, cyst wall calcifications, enhancing capsules, and occasionally mural nodules. MCNs typically do not cause dilatation of the biliary or pancreatic ductal system but can be associated with distal pancreatic atrophy. They may be associated with lymphadenopathy but generally are not associated with peripancreatic fat infiltration or vascular involvement.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "Cysts with at least 2 high-risk features (size >3 cm, dilated MPD or solid component) should have EUS-FNA. After reassuring EUS- FNA, MR imaging surveillance is recommended after 1 year and then every 2 years; substantial changes in the cyst by imaging should result in repeat EUS-FNA. Cysts with solid components and a dilated MPD or concerning EUS-FNA should be offered surgery. After excision of cancer or a cystic/mucin-producing neoplasm with dysplasia, the residual pancreas should be examined using MR imaging surveillance every 2 years.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “A of carcinoembryonic antigen (CEA) level greater than or equal to 192 ng/mL and molecular analysis, including DNA concentration, K-RAS mutations, and allelic imbalances, improves sensitivity in diagnosing mucinous from nonmucinous neoplasms, although CEA cutoff levels may be specific to the individual laboratory. CA 19-9 analysis of cyst aspirate is not useful. Large amounts of PC fluid DNA, high- amplitude mutations, and specific mutation acqui- sition sequences are predictors of malignancy.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "Genes associated with IPMNs include KRAS, GNAS, RNF43, TP53, PIK3CA, PTEN, CDKN2A, and SMAD4.46 MCNs are associated with genetic alterations in KRAS, RNF43, TP53, PIK3CA, PTEN, CDKN2A, and SMAD4. SCNs have a typical CEA fluid analysis of less than 5 ng/mL and low viscosity and are associated with mutations in the VHL gene. Fluid viscosity can be used to differentiate between mucinous and nonmucinous cysts.The string sign is measured by the maximal length of mucus string between the thumb and index finger of the examiner; a positive string sign is if the mucus measures at least 3 mm.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “Incidental PCs commonly are encountered in a radiology practice. Some cystic masses of the pancreas, in particular pseudocysts, usually can be characterized accurately and adequately by a combination of imaging, history, and follow-up. Other PCs require further evaluation with EUS with FNA. Because some have malignant potential, many PCs require clinical and imaging follow-up. There are several available societal guidelines to help plan patient follow-up, with recent updates. The care of patients with PCs ideally is a multidisciplinary effort among radiologists, pathologists, surgeons, and gastroenterologists for optimal patient management.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “Although typically solid and hyperenhancing, pancreatic neuroendocrine tumors can be mixed cystic and solid and, rarely, almost entirely cystic with a thick hyperenhancing rim or mural nodularity. These tumors can be multifocal, and, although they usually are sporadic, they can be associated with neurofibromatosis 1, multiple endocrine neoplasia type 1, or VHL disease. There is a relatively high degree of metastatic disease, either to lymph nodes or liver.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “Although the classic appearance of PDAC is a solid, infiltrating mass, it may develop cystic features , including large duct cysts, neoplastic mucinous cysts, colloid carcinomas, and degenerative cystic change. An obstructing mass can cause retention cysts or pseudocysts from pancreatitis There rarely can be a combination of these processes with the same patient, that is, areas of cystic degeneration/necrosis, as well as cystic changes related to secondary pancreatitis. Clear ductal obstruction should raise concern for PDAC.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “SPENs are relatively rare low-grade malignant tumors that typically affect young women. These tumors can be solid, cystic, or mixed and frequently develop internal hemorrhage. A well- defined thick enhancing capsule is typical. These usually are large (average 9 cm) and more often in the tail.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - - Imaging alone cannot always differentiate benign pancreatic cysts from pancreatic cysts with malignant potential.
- Small indeterminate pancreatic cysts need to be followed-up, since invasive testing and re- sections are typically reserved for larger or growing cysts or definitively malignant cysts.
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “MCNs occur almost exclusively in women and more commonly are found in the pancreatic tail. MCNs are oval or round and can show septations, cyst wall calcifications, enhancing capsules, and occasionally mural nodules. MCNs typically do not cause dilatation of the biliary or pancreatic ductal system but can be associated with distal pancreatic atrophy. They may be associated with lymphadenopathy but generally are not associated with peripancreatic fat infiltration or vascular involvement.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - Cystic Pancreatic Lesions
- Pancreatic Pseudocyst
- Serous cystadenoma
- Lymphoepithelial Cyst
- IPMN
- MCN (Mucinous Cystic Neoplasm)
- Solid and Pseudopapillary Epithelial Neoplasms (SPEN)
- Cystic Features of Pancreatic Ductal Adenocarcinoma
- Cystic Neuroendocrine Tumor - “Predictors of high-grade dysplasia (MCN) include size greater 8.5 cm.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - Summary of guidelines for follow-up of incidental pancreatic cysts
- MCN vs SCN using EUS
- “Mucinous cystic neoplasms (MCN) and serous cystic neoplasms (SCN) account for a large portion of solitary pancreatic cystic neoplasms (PCN). In this study we implemented a convolutional neural network (CNN) model using ResNet50 to differentiate between MCN and SCN. The training data were collected retrospectively from 59 MCN and 49 SCN patients from two different hospitals. Data augmentation was used to enhance the size and quality of training datasets. Fine-tuning training approaches were utilized by adopting the pre-trained model from transfer learning while training selected layers. Testing of the network was conducted by varying the endoscopic ultrasonography (EUS) image sizes and positions to evaluate the network performance for differentiation. The proposed network model achieved up to 82.75% accuracy and a 0.88 (95% CI: 0.817–0.930) area under curve (AUC) score.”
Deep Learning-Based Differentiation between Mucinous Cystic Neoplasm and Serous Cystic Neoplasm in the Pancreas Using Endoscopic Ultrasonography
Leang Sim Nguon et al.
Diagnostics 2021, 11, 1052. https://doi.org/10.3390/diagnostics11061052 
- “This study aimed to investigate the diagnostic ability of carcinoembryonic antigen (CEA), cytology, and artificial intelligence (AI) by deep learning using cyst fluid in differentiating malignant from benign cystic lesions. We retrospectively reviewed 85 patients who underwent pancreatic cyst fluid analysis of surgical specimens or endoscopic ultrasound-guided fine-needle aspiration specimens. AI using deep learning was used to construct a diagnostic algorithm. CEA, carbohydrate antigen 19-9, carbohydrate antigen 125, amylase in the cyst fluid, sex, cyst location, connection of the pancreatic duct and cyst, type of cyst, and cytology were keyed into the AI algorithm, and the malignant predictive value of the output was calculated. Area under receiver-operating characteristics curves for the diagnostic ability of malignant cystic lesions were 0.719 (CEA), 0.739 (cytology), and 0.966 (AI). In the diagnostic ability of malignant cystic lesions, sensitivity, specificity, and accuracy of AI were 95.7%, 91.9%, and 92.9%, respectively. AI sensitivity was higher than that of CEA (60.9%, p = 0.021) and cytology (47.8%, p = 0.001). AI accuracy was also higher than CEA (71.8%, p < 0.001) and cytology (85.9%, p = 0.210). AI may improve the diagnostic ability in differentiating malignant from benign pancreatic cystic lesions.”
Diagnostic ability of artificial intelligence using deep learning analysis of cyst fluid in differentiating malignant from benign pancreatic cystic lesions
Yusuke Kurita et al.
Scientific Reports | (2019) 9:6893 - "Although cytology had excellent specificity, it has a limited role because of its lack of sensitivity in previous studies30–32. In the present study, the sensitivity of cytology in differentiating malignant from benign cystic lesions was 47.8%. Thus, we constructed AI using deep learning algorithm for differentiating malignant from benign pancreatic cystic lesions based on the analysis of pancreatic cyst fluid and clinical data.”
Diagnostic ability of artificial intelligence using deep learning analysis of cyst fluid in differentiating malignant from benign pancreatic cystic lesions
Yusuke Kurita et al.
Scientific Reports | (2019) 9:6893 - "In this study, AI using deep learning analyzed pancreatic cyst fluid and clinical data. By using this deep learning method, AI learns the characteristics of malignant cystic lesions by combining cyst fluid analysis and clinical data, and AI can possibly exclude the bias generated by human judgment. Although it is difficult for clinicians to diagnose malignant pancreatic cystic lesions by cyst fluid analysis and clinical data, AI using deep learning achieved adequate diagnostic ability in differentiating malignant from benign cystic lesions compared to cyst fluid analysis such as CEA and cytology. AI and CEA were also significant factor in the multivariate analysis of malignant cystic lesion. Specifically, although it is generally a problem that cytology diagnosis has low sensitivity, AI using deep learning achieved high sensitivity (95.7%).”
Diagnostic ability of artificial intelligence using deep learning analysis of cyst fluid in differentiating malignant from benign pancreatic cystic lesions
Yusuke Kurita et al.
Scientific Reports | (2019) 9:6893 
- "Chakraborty et al. utilized radiomics features extracted from pre- surgical CT images, as markers for assessment of malignancy risk of BD- IPMNs. Similar to the previous studies, they categorized their cohort of 103 patients into low-risk and high-risk IPMNs based on final pathological findings after cyst resection. They extracted four new radio- graphically inspired features (enhanced boundary fraction, enhanced inside fraction, filled largest connected component fraction and average weighted eccentricity), along with intensity and orientation-based texture features from the CT images.”
Radiomics in stratification of pancreatic cystic lesions: Machine learning in action
Vipin Dalala et al.
Cancer Letters,Volume 469,2020,Pages 228-237
- Pancreatic Cysts on CT: Definitely Benign
- Serous cystic neoplasms (SCNs)
- Pancreatitis-Associated Fluid Collections
- Congenital or Syndromic Pancreatic Cysts
- Lymphoepithelial Cyst
- “Incidental pancreatic cysts (PCs) are commonly encountered in radiology practice. The prevalence rate of PCs is estimated at 2.5%. There is a 9% reported incidence on computed tomography (CT) and a 27% incidence on MR imaging. PCs are a heterogeneous group, including intraductal papillary mucinous neoplasm (IPMN), serous cystic neoplasm (SCN), and mucinous cystic neoplasm (MCN). Non-neoplastic PCs are pancreatic pseudocysts (common), epithelial cysts (uncommon), and lymphoepithelial cysts (rare).”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "Pancreatic CT is performed in the pancreatic parenchymal and portal venous phases. The pancreatic phase represents peak pancreatic parenchymal enhancement, which occurs 40 sec- onds to 45 seconds following the IV injection of contrast. The portal venous phase is obtained 70 seconds to 75 seconds following the IV injection of contrast. Because the time of peak parenchymal enhancement can vary based on a patient’s physiology, an accurate method for achieving this phase entails triggering imaging at 16 seconds following the acquisition of a threshold of 175 Hounsfield units in the upper abdominal aorta.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629- Cystic Pancreas Lesions: Definitely Benign
- Serous cystic neoplasm
- Pancreatic pseudocyst
- Lymphoepithelial cyst - Cystic Pancreas Lesions: Potentially or Definitely Malignant
- Intraductal Papillary Mucinous Neoplasm
- Mucinous Cystic Neoplasm - Cystic Pancreas Lesions: Mimics
- Solid and Pseudopapillary Epithelial Neoplasms
- Cystic Features of Pancreatic Ductal Adenocarcinoma
- Cystic Neuroendocrine Tumor - "SCNs typically are described as having a honey- comb or multilocular appearance with or without a central scar. However, there can be variations in the morphologic appearance with polycystic, oligocystic, and solid patterns described. Microcystic morphology is more common in SCNs. The classic imaging features are a lobulated external contour and central scar with stellate calcification. SCNs rarely demonstrate peripheral enhancing capsule or mural nodules.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "MCN occur almost exclusively in women and more commonly are found in the pancreatic tail. MCNs are oval or round and can show septations, cyst wall calcifications, enhancing capsules, and occasionally mural nodules. MCNs typically do not cause dilatation of the biliary or pancreatic ductal system but can be associated with distal pancreatic atrophy. They may be associated with lymphadenopathy but generally are not associated with peripancreatic fat infiltration or vascular involvement.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "Cysts with at least 2 high-risk features (size >3 cm, dilated MPD or solid component) should have EUS-FNA. After reassuring EUS- FNA, MR imaging surveillance is recommended after 1 year and then every 2 years; substantial changes in the cyst by imaging should result in repeat EUS-FNA. Cysts with solid components and a dilated MPD or concerning EUS-FNA should be offered surgery. After excision of cancer or a cystic/mucin-producing neoplasm with dysplasia, the residual pancreas should be examined using MR imaging surveillance every 2 years.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “A of carcinoembryonic antigen (CEA) level greater than or equal to 192 ng/mL and molecular analysis, including DNA concentration, K-RAS mutations, and allelic imbalances, improves sensitivity in diagnosing mucinous from nonmucinous neoplasms, although CEA cutoff levels may be specific to the individual laboratory. CA 19-9 analysis of cyst aspirate is not useful. Large amounts of PC fluid DNA, high- amplitude mutations, and specific mutation acqui- sition sequences are predictors of malignancy.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - "Genes associated with IPMNs include KRAS, GNAS, RNF43, TP53, PIK3CA, PTEN, CDKN2A, and SMAD4.46 MCNs are associated with genetic alterations in KRAS, RNF43, TP53, PIK3CA, PTEN, CDKN2A, and SMAD4. SCNs have a typical CEA fluid analysis of less than 5 ng/mL and low viscosity and are associated with mutations in the VHL gene. Fluid viscosity can be used to differentiate between mucinous and nonmucinous cysts.The string sign is measured by the maximal length of mucus string between the thumb and index finger of the examiner; a positive string sign is if the mucus measures at least 3 mm.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “Incidental PCs commonly are encountered in a radiology practice. Some cystic masses of the pancreas, in particular pseudocysts, usually can be characterized accurately and adequately by a combination of imaging, history, and follow-up. Other PCs require further evaluation with EUS with FNA. Because some have malignant potential, many PCs require clinical and imaging follow-up. There are several available societal guidelines to help plan patient follow-up, with recent updates. The care of patients with PCs ideally is a multidisciplinary effort among radiologists, pathologists, surgeons, and gastroenterologists for optimal patient management.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “Although the classic appearance of PDAC is a solid, infiltrating mass, it may develop cystic features , including large duct cysts, neoplastic mucinous cysts, colloid carcinomas, and degenerative cystic change. An obstructing mass can cause retention cysts or pseudocysts from pancreatitis There rarely can be a combination of these processes with the same patient, that is, areas of cystic degeneration/necrosis, as well as cystic changes related to secondary pancreatitis. Clear ductal obstruction should raise concern for PDAC.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 - “SPENs are relatively rare low-grade malignant tumors that typically affect young women. These tumors can be solid, cystic, or mixed and frequently develop internal hemorrhage. A well- defined thick enhancing capsule is typical. These usually are large (average 9 cm) and more often in the tail.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629 
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629
Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case‑based approach with imaging–pathologic correlation
Kumi Ozaki et al.
Japanese Journal of Radiology https://doi.org/10.1007/s11604-020-01032-1- “They are divided into three categories: (1) primary neoplastic cysts, which include serous cystadenoma , mucinous cystic neoplasm (MCN), intraductal papillary mucinous neoplasm (IPMN), and solid pseudopapillary neoplasm (SPN); non-neoplastic cysts, which include pseudocyst , congenital cyst, retention cyst, hydatid cyst, lymphoepithelial cyst, and epidermoid cyst of intrapancreatic accessory spleen; and various solid neoplasms undergoing cystic changes including neuroendocrine tumor, metastatic tumor, ductal adenocarcinoma, and acinar cell cystadenocarcinoma.”
Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case‑based approach with imaging–pathologic correlation
Kumi Ozaki et al.
Japanese Journal of Radiology https://doi.org/10.1007/s11604-020-01032-1 - "Unilocular cysts are thin-walled simple cystic lesions without solid components or internal septa. Pseudocyst is the most common lesion in this category. IPMN and MCN are also common, whereas uncommon lesions include serous cystadenoma (oligocystic variant < 10%,lymphoepithelial cyst, epidermoid cyst, and neuroendocrine tumors with cystic degeneration. Neuroendocrine neoplasm, especially if small, can be exclusively cystic, making the differential diagnosis with cystic neoplasms, unilocular serous cystadenomas or retention cysts extremely difficult.”
Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case‑based approach with imaging–pathologic correlation
Kumi Ozaki et al.
Japanese Journal of Radiology https://doi.org/10.1007/s11604-020-01032-1 - "Pancreatic cystic lesions can occur in genetic diseases, such as Von Hippel–Lindau disease, multiple endocrine neoplasia (MEN) type 1, cystic fibrosis, and autosomal- dominant polycystic kidney disease (ADPKD). Pancreatic cystic lesions associated with these genetic disorders can be highly multifocal.”
Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case‑based approach with imaging–pathologic correlation
Kumi Ozaki et al.
Japanese Journal of Radiology https://doi.org/10.1007/s11604-020-01032-1 
Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case‑based approach with imaging–pathologic correlation
Kumi Ozaki et al.
Japanese Journal of Radiology https://doi.org/10.1007/s11604-020-01032-1- "An important differentiating feature between MCN or serous cystadenomas and IPMN is visualization of pancreatic ductal communication. If a clear channel of communication with the pancreatic duct is visualized, the diagnosis of branch duct IPMN is almost certain because serous cystadenomas and MCN do not communicate with the pancreatic ductal system. In contrast, up to 65% of pseudocysts may show communication with the ductal system. Other cystic lesions, such as MCN and serous cystadenoma, do not usually communicate with the pancreatic ductal system.”
Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case‑based approach with imaging–pathologic correlation
Kumi Ozaki et al.
Japanese Journal of Radiology https://doi.org/10.1007/s11604-020-01032-1
- Purpose: The imaging features of serous cystadenomas (SCAs) overlap with those of mucinous cystic neoplasms (MCNs) and branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), and an accurate preoperative diagnosis is important for clinical treatment due to their different biological behaviors. The aim of this study was to provide a computed tomographic (CT) feature for the diagnosis of SCAs and estimate whether the “circumvascular sign” can contribute to the discrimination of SCAs from MCNs and BD-IPMNs.
Conclusion: Pancreatic cystic neoplasms that show central scarring, central calcification or the circumvascular sign on CT could be diagnosed as SCAs. When either of the first two features is combined with the circumvascular sign, the diagnostic sensitivity could be increased.
Discrimination of serous cystadenoma from mucinous cystic neoplasm and branch duct intraductal papillary mucinous neoplasm in the pancreas with CT
Guang‐xian Wang et al.
Abdominal Radiology (2020) 45:2772–2778 - “The “circumvascular sign” was defined as the presence of some abnormal arteries surrounding the lesion on arterial phase CT. In addition, tumor size, tumor patterns, and degree of enhancement were also recorded.”
Discrimination of serous cystadenoma from mucinous cystic neoplasm and branch duct intraductal papillary mucinous neoplasm in the pancreas with CT
Guang‐xian Wang et al.
Abdominal Radiology (2020) 45:2772–2778 - “The central scarring, central calcification and circumvas- cular sign had high specificities, 97.7%, 100% and 100%, respectively. However, the sensitivities of central scarring and central calcification were low, 36.7% and 23.3%, respec- tively. Only the circumvascular sign had moderate sensitivity (76.7%). Combining the circumvascular sign with either of the other features increased the sensitivity for the diagnosis of SCAs to 83.3%.”
Discrimination of serous cystadenoma from mucinous cystic neoplasm and branch duct intraductal papillary mucinous neoplasm in the pancreas with CT
Guang‐xian Wang et al.
Abdominal Radiology (2020) 45:2772–2778 - "In conclusion, this study showed that central scarring, central calcification and the circumvascular sign were able to distinguish SCAs from MCNs and BP-IPMNs. When either central scarring or central calcification was combined with the circumvascular sign, the sensitivity for the diagnosis of SCAs increased. The circumvascular sign may be a novel diagnostic and differential diagnostic sign for SCAs.”
Discrimination of serous cystadenoma from mucinous cystic neoplasm and branch duct intraductal papillary mucinous neoplasm in the pancreas with CT
Guang‐xian Wang et al.
Abdominal Radiology (2020) 45:2772–2778
- “PNS tumors represent an exceedingly rare tumor of the pancreas. They are generally benign neoplasms of pancreatic nerve sheaths originating in the vagus nerve and often misdiagnosed as cystic pancreatic tumors.”
Pancreatic Nerve Sheath Tumors: a Single Institutional Series and Systematic Review of the Literature
Ammar A. Javed, Michael J. Wright, Alina Hasanain, Kevin Chan, Richard A. Burkhart, Ralph H. Hruban, Elizabeth Thompson, Elliot K. Fishman, John L. Cameron, Jin He, Christopher L. Wolfgang, Matthew J. Weiss
Journal of Gastrointestinal Surgery (2020) 24:841–848 - "In both our institutional experience and literature, all cases of resected PNS tumors achieved good long-term outcomes; none of the patients developing recurrence at the last follow- up. PNS tumors are generally benign, and are believed to be relatively indolent tumors. A diagnosis of PNS tumor should be considered in the setting of heterogeneous masses of the pancreas particularly with calcification, hemorrhage, or hyalinization. Accurate diagnosis of pancreatic cystic lesions remains inexact; in fact, up to 25% of IPMNs are misdiagnosed preoperatively.”
Pancreatic Nerve Sheath Tumors: a Single Institutional Series and Systematic Review of the Literature
Ammar A. Javed, Michael J. Wright, Alina Hasanain, Kevin Chan, Richard A. Burkhart, Ralph H. Hruban, Elizabeth Thompson, Elliot K. Fishman, John L. Cameron, Jin He, Christopher L. Wolfgang, Matthew J. Weiss
Journal of Gastrointestinal Surgery (2020) 24:841–848
- Objectives The aim of this study was to assess the characteristic radiological features of early-stage pancreatic cancer (PC).
Results Characteristic radiological features before diagnosis of PC were classified into the following 9 features: pancreatic duct ectasia (n = 16), focal low-density area (n = 15), change of cyst size (n = 8), localized tissue atrophy (n = 7), distal atrophy (n = 4), mass in pancreatic lipomatosis tissue (n = 2), mass concomitant with the already known cyst (n = 2), protrusion (n = 1), and parenchymal disproportion (n = 1). Fifty-three cases (84%) had more than one characteristic radiological feature before diagnosis of PC, and their median observation period until diagnosis was 24 (range, 1–120) months.
Conclusions The 9 characteristic radiological features provide an opportunity to diagnose PC at an early stage.
Characteristic Radiological Features of Retrospectively Diagnosed Pancreatic Cancers
Fukushima Daiz, Nishino Noriyuki, Hamada Koichi et al.
Pancreas: January 2020 - Volume 49 - Issue 1 - p 76–88 - • Pancreatic duct ectasia, focal LDA, and distal atrophy—these are 3 classical features of PC. A lump of cells with or without necrotic tissue was shown as having focal LDA. Pancreatic duct ectasia was caused by ductal obstruction or overflow of pancreatic juice. Distal atrophy was caused by chronic inflammation from ductal obstruction or by fibrosis from PC.
• Change in cyst size—2 patterns of change in cyst size before PC diagnosis were recognized, including both enlarged and reduced cases.
• Localized tissue atrophy—focal pancreatic tissue atrophy without distal atrophy.
• Mass in pancreatic lipomatosis tissue—a mass in pancreatic tissue with lipomatosis.
• Mass concomitant with the already known cyst—mass that occurred in a part of pancreas other than that where the cyst was previously confirmed.
• Protrusion—an unnaturally protruding lesion.
• Parenchymal disproportion—an unnaturally thick lesion compared with the surrounding tissue or with the previous images of the same area of the pancreas.
Characteristic Radiological Features of Retrospectively Diagnosed Pancreatic Cancers
Fukushima Daiz, Nishino Noriyuki, Hamada Koichi et al.
Pancreas: January 2020 - Volume 49 - Issue 1 - p 76–88 - “The 9 characteristic radiological features before typically observable PC development provide an opportunity of early PC diagnosis using precise examinations such as EUS, MDCT, and ERCP.”
Characteristic Radiological Features of Retrospectively Diagnosed Pancreatic Cancers
Fukushima Daiz, Nishino Noriyuki, Hamada Koichi et al.
Pancreas: January 2020 - Volume 49 - Issue 1 - p 76–88 - “The 5-year overall survival of PC is 7.7%, despite recent developments in diagnostic imaging; however, that of PC with a tumor size of within 10 mm is reported to be 80.4%. Early diagnosis is therefore expected to be the only breakthrough in improving the overall survival of PC. On the other hand, according to the genetic progression model of pancreatic carcinogenesis, it takes about 6.8 years for pancreatic intraepithelial neoplasia (PanIN) to develop into an invasive ductal carcinoma. Two to 3 years after PanIN development is regarded as the most important stage for early PC diagnosis. It is therefore clinically necessary to point out the high-risk radiological features 2 to 3 years from PanIN development.”
Characteristic Radiological Features of Retrospectively Diagnosed Pancreatic Cancers
Fukushima Daiz, Nishino Noriyuki, Hamada Koichi et al.
Pancreas: January 2020 - Volume 49 - Issue 1 - p 76–88 - "The CT scans for 64% (34/53) of the patients with characteristic radiological features were not performed for the purpose of scanning for biliary tract disease, pancreatic disease, back pain, or abdominal symptoms. Occult PC must be taken into consideration even when CT is performed for purposes other than PC-related risk factors.”
Characteristic Radiological Features of Retrospectively Diagnosed Pancreatic Cancers
Fukushima Daiz, Nishino Noriyuki, Hamada Koichi et al.
Pancreas: January 2020 - Volume 49 - Issue 1 - p 76–88 - OBJECTIVES To determine the level of survival disparity between black and white patients in a modern PDAC cohort and whether treatment inequity is associated with such a disparity.
CONCLUSIONS AND RELEVANCE Black patients with PDAC present at younger ages and with more advanced disease than white patients, suggesting that differences in tumor biology may exist. Black patients receive less treatment stage for stage and fewer surgical procedures for resectable cancers than white patients; these findings may be only partly associated with socioeconomic differences. When disease stage and treatment were controlled for, black patients had no decrease in survival.
Association of Treatment Inequity and Ancestry With Pancreatic Ductal Adenocarcinoma Survival
Heller DR et al.
JAMA Surg. Published online December 04, 2019. doi:https://doi.org/10.1001/jamasurg.2019.5047 - IMPORTANCE Pancreatic ductal adenocarcinoma (PDAC) has a higher incidence and worse outcomes among black patients than white patients, potentially owing to a combination of socioeconomic, biological, and treatment differences. The role that these differences play remains unknown.
Association of Treatment Inequity and Ancestry With Pancreatic Ductal Adenocarcinoma Survival
Heller DR et al.
JAMA Surg. Published online December 04, 2019. doi:https://doi.org/10.1001/jamasurg.2019.5047 - “The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: ‘resectable,’ ‘borderline resectable,’ and ‘unresectable’. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Naveen M. Kulkarn et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-02289-5 - “In addition to the above measures, serum CA 19-9 level (drawn following biliary decompression and with confirmation that serum bilirubin levels have normalized) and baseline standard laboratory studies are also recommended. Not all patients with PDAC have tumors that express CA 19-9, a sialylated Lewis A blood group antigen. CA 19-9 can be a good diagnostic and prognostic marker in those tumors that express it. Preoperative CA 19-9 levels have shown correlation with resectability and can provide additional information for staging. The NCCN recommends measurement of serum CA 19-9 levels before and after neoadjuvant.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Naveen M. Kulkarn et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-02289-5 - “Unlike patients with clearly resectable disease, patients with borderline resectable disease are at high risk for a positive surgical margin and recurrence in the setting of upfront surgery. For patients with borderline resectable disease, the aim of neoadjuvant therapy is to sufficiently treat the tumor so that a negative resection margin can be achieved even though such a change may not be apparent at imaging. Treatment and imaging features of borderline resectable disease will be discussed later in this article."
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Naveen M. Kulkarn et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-02289-5 
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines,and borderline resectable disease
Naveen M. Kulkarn et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-02289-5- “The discrimination of mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC) is a central diagnostic dilemma. It is important to differentiate these entities since they have markedly different prognoses and management. Importantly, the appearance of these two entities significantly overlaps on a variety of imaging modalities. However, there are imaging features that may be suggestive of one entity more than the other. MFCP and PDAC may show different enhancement patterns on perfusion computed tomography (CT) and/or dynamic contrast-enhanced MRI (DCE-MRI).”
Pancreatitis and PDAC: association and differentiation
Sherif B. Elsherif et al.
Abdominal Radiology 2019 (in press) https://doi.org/10.1007/s00261-019-02292-w - “Autoimmune pancreatitis (AIP) is a special subtype of CP that is characterized by a persistent pancreatic inflammation secondary to autoimmune disease and accounts for 2–11% of all CP cases. AIP consists of two distinct histologic patterns designated as type 1 and type 2 AIP. Early diagnosis of AIP is important since it responds dramatically to treatment with steroids. AIP can present as diffuse, focal, or multifocal disease; when manifesting as focal disease, it most often involves the pancreatic head, mimicking PDAC. On CT, it presents as diffuse or focal enlargement of the pancreas with a peripancreatic rim, or low attenuation “halo”.”
Pancreatitis and PDAC: association and differentiation
Sherif B. Elsherif et al.
Abdominal Radiology 2019 (in press) https://doi.org/10.1007/s00261-019-02292-w
- “In conclusion, our study provided preliminary evidence that textural features derived from CT images were useful in differential diagnosis of pancreatic mucinous cystadenomas and serous cystadenomas, which may provide a non-invasive approach to determine whether surgery is needed in clinical practice. However, multicentre studies with larger sample size are needed to confirm these results.”
Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning
Yang J et al.
Front. Oncol., 12 June 2019 /doi.org/10.3389/fonc.2019.00494 - “Results: Radiomics features extracted from contrast-enhanced CT were able to discriminate pancreatic mucinous cystadenomas from serous cystadenomas in both the training group (slice thickness of 2 mm, AUC 0.77, sensitivity 0.95, specificity 0.83, accuracy 0.85; slice thickness of 5 mm, AUC 0.72, sensitivity 0.90, specificity 0.84, accuracy 0.86) and the validation group (slice thickness of 2 mm, AUC 0.66, sensitivity 0.86, specificity 0.71, accuracy 0.74; slice thickness of 5 mm, AUC 0.75, sensitivity 0.85, specificity 0.83, accuracy 0.83).
Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning
Yang J et al.
Front. Oncol., 12 June 2019 /doi.org/10.3389/fonc.2019.00494 - The parameters derived from texture analysis and several clinicopathological characteristic (age, gender, size, location of lesions, enhancement of peripheral wall, mural nodules, and calcification of lesions) were analyzed using random forest and Least Absolute Shrinkage and Selection Operator (LASSO) methods. In the group of 2 mm slice thickness, 22 parameters were obtained using the random forest analysis and 12 parameters were obtained using LASSO method; 5 overlapping parameters were discovered. In the group of 5 mm slice thickness, 18 parameters were obtained using the random forest analysis and 14 parameters were obtained using LASSO method; 4 overlapping parameters were discovered. Those selected textural parameters were given as mean ± standard deviation. Statistical differences of textural parameters were analyzed using independent sample t-test. A p-value of <0.05 was considered significant.
Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning
Yang J et al.
Front. Oncol., 12 June 2019 /doi.org/10.3389/fonc.2019.00494 - Given the benign nature of pancreatic serous cystadenomas and malignant potential of mucinous cystadenomas, resection is not suggested for most of the patients with serous cystadenoma while surgical treatment is recommended for all surgical fit patients with mucinous cystadenoma . Therefore, preoperative differential diagnosis is critical. Currently, cross- sectional imaging, endoscopic ultrasound (EUS), fine-needle aspiration (FNA) biopsy and cyst fluid analysis were frequently employed to assist in the differential diagnosis. EUS with cyst fluid analysis is the most important mean to distinguish pancreatic mucinous cystadenomas from serous cystadenomas. A cyst fluid carcinoembryonic antigen (CEA) level > 192 ng/mL has been reported to be useful for identification of mucinous cystadenomas, with a sensitivity of 73% and specificity of 84%. However, cyst fluid analysis is limited by its invasiveness
Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning
Yang J et al.
Front. Oncol., 12 June 2019 /doi.org/10.3389/fonc.2019.00494 - In general, the heterogeneity of tissue is composed of multiple texture patterns, so a single textural parameter cannot fully display the gross textural characteristics of tumor. In the preliminary analysis of this study, we also tried to analyze individual factors, and the results were not satisfactory. In consideration of this, a complex of integrated different textural parameters is required to represent gross texture of tumor more comprehensively. Random forest model, a powerful machine-learning approach, has proved successful in classifying subjects into the correct group. Previous studies have also indicated that random forest model could be used in the analysis of textural features. In this study, random forest model was able to discriminate between pancreatic mucinous cystadenomas and serous cystadenomas.
Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning
Yang J et al.
Front. Oncol., 12 June 2019 /doi.org/10.3389/fonc.2019.00494 - In conclusion, our study provided preliminary evidence that analysis texture of lesions in CT images was a reliable method to differentiate diagnosis of pancreatic mucinous cystadenomas and serous cystadenomas, which may provide a convenient, non-invasive and repeatable approach to determine whether surgery is needed in clinical practice. However, multicentre studies with larger sample size are needed to confirm these results.
Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning
Yang J et al.
Front. Oncol., 12 June 2019 /doi.org/10.3389/fonc.2019.00494 - “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
Linda C. Chu, MD,* Aatur D. Singhi, MD, PhD,† Ralph H. Hruban, MD,‡ and Elliot K. Fishman, MD*
J Comput Assist Tomogr 2014;38: - Conclusions: 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
Linda C. Chu, MD,* Aatur D. Singhi, MD, PhD,† Ralph H. Hruban, MD,‡ and Elliot K. Fishman, MD*
J Comput Assist Tomogr 2014;38:
- Serous cystadenoma
• Imaging Findings
• Polycystic: cysts are <2cm; oligocystic cysts are > 2cm
• Usually in head, 40% in tail
• Fibrous enhancing septations
• Central scar with coarse calcification (30%)
• Does not communicate with duct. Can obstruct duct when large
• Atypical findings: giant >10 cm, intratumoral hemorrhage, solid appearance (pNET mimic), unilocular with calcification (pseudocyst or mucinous mimic) - Serous cystadenoma
• Frequently incidental cystic tumors found in woman in the 5th to 7th decades.
• Tumors >4 cm are more likely to be symptomatic
• Three morphologic types: polycystic (70%), honeycomb (20%) or oligocystic (10%) - Correlation between CT Attenuation and Pathologic Classification
• The polycystic pattern and cystic and solid pattern fit into the microcystic category and represented the most common CT appearance of serous cystadenomas
• Most of the solid cystadenomas fit into the honeycomb category, in which the individual cysts were too small to be resolved on CT
• One of the solid cystadenomas was a rare solid variant of serous cystadenoma, which did not contain any cystic spaces on histopathology - Correlation between CT Attenuation and Pathologic Classification
- CT Attenuation As Compared to Other Cystic Pancreatic Lesions
• Chalian et al. (2011) reported mean CT attenuation values of unilocular cystic pancreatic lesions during the pancreatic parenchymal phase:
• Pseudocyst 18.9 HU ± 3.8
• Mucinous cystic neoplasms 13 HU ± 2.5
• IPMNs 11.4 HU ± 2.7
- 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 oldHow 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
- MultiplicityFive 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