Optimale Hormontherapie George Thalmann Urologische Universitätsklinik Bern.
Pancreatic Cystic Neoplasms Bible Class 4th Sept.2013 Universitätsklinik für Viszerale Chirurgie...
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Transcript of Pancreatic Cystic Neoplasms Bible Class 4th Sept.2013 Universitätsklinik für Viszerale Chirurgie...
Pancreatic Cystic Neoplasms
Bible Class4th Sept.2013
Universitätsklinik für Viszerale Chirurgie und Medizin
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
What type of pancreatic cysts exist ?
Acquired Cysts:
Congenital Cysts:
Cystic Neoplasms:
Post-inflammatory fluid collectionPseudo-,-PseudocystPostnecrotic sequestrumParasitic, Ecchinococcal etc.
True cystsEnterogenous cysts/ duplication cysts(Epi)dermoid cysts, EndometriosePolycystic diseases; Cystic Fibrosis
Cystic Neoplasms:
- IPMN: Intraductal papillary mucinous neoplasm
- MCN: Mucinous cystic neoplasm
- SCN: Serous cystic adenoma/ neoplasm
- SPN: Solid pseudopapillary neoplasm
- CPEN: Cystic pancreatic endocrine neoplasm
Why is this differentiation important ?
Risk Malignancy
Benign
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
How frequent are neoplastic pancreatic cystic lesions ?
Average: 2.5%
Age > 70 years: 10-20%*
*: MRI in non-pancreatic disease: 20% of 1444 patients; Zhang XM et al. Radiology 2002
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Key features: Serous Cystic Neoplasm
Malignant potential:
Location:
Demographics, rate:
Morphology: micro-, oligo-, macrocystic
typically: multicystic cluster (each < 2 cm) = honeycumbed
No communication with pancreatic duct
Stroma: (central fibrous and) calcified (stellate scar)
NO
throughout the pancreas
(older) women (80%), 15-20% of PCNs
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Key features: IPMN
Types:
Malignant potential:
Location:
Demographics, rate:
Morphology:
Yes (esp. main/combined duct IPMN)
M: head BD: multifocal !!
Equal m/w, middle-age/old; >25% of PCNs
Main-, branch-duct, mixed type
Cystic dilatation main (> 6 mm) or side
branches; M: Fish-mouth, globules of mucin (= masses)
Stroma: Lack of ovarian stroma (vs. MCN)
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Key features: MCN
Malignant potential:
Location:
Demographics, rate:
Morphology:
Yes (but lower than IPMN)
Body/tail (95%), always single lesion!
Middle-aged women (95%), 25% of PCNs
thick-walled single cyst, often septations
Epithelial layer with mucin-producing cells, ovarian-like stroma
No communication with pancreatic duct
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Risk of malignancy in pancreatic neoplastic cysts ?
IPMN: BD-:
MD-:
MCN:
SCN:
SPN:
CPEN:
1: Sakorafas GH et al. Surg Oncol. 2011; 2 Sakorafas GH et al. Surg Oncol 2012
++ ̴ 40% (6-46%) Risk of HGD/ malignancy 1
++++ ̴ 65% (57-92%) Risk of HGD/ malignancy in 5 y 1
++ 6-36% Prevalence malignancy 1
(+) VERY low (malignant = serous cystadenocarcinoma)
+ Low malignant potential 2
Variable 2
What factors determine malignant risk in IPMN/MCN?
Size
Histopathological type
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
What are high-risk stigmata for malignancy in IPMN/MCN?
Obstructive jaundice (and cystic lesion of the pa-head)
Enhancing solid component within cyst
Main pancreatic duct > 10 mm in size
Consequence?
Consider surgery, if clinically appropriate
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
If no high-risk stigmata in IPMN/MCN:What are worrisome features ?
Clinical: PancreatitisImaging: Cyst > 3 cm
Thickened/enhancing cyst wallsMain duct size 5-9 mmNon-enhancing mural noduleAbrupt change in caliber of pancreatic ductwith distal pancreatic atrophy
Consequence?
Endo-Sonography
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
What are the advantages of EUS in diagnostic workup of pancreatic cysts ?
Superior, higher-resolution imaging of the pancreas
(ductal communication, additional (smaller) cysts, nodules etc.)
Fine-needle-aspiration (FNA): sampling fluid for
Cytology and tumor markers
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Operator-Dependent Investigation
Sampling Error
Contamination (gastric wall)
Low cellularity -> Low senstivity
e.g. SCN only 30-40% enough cells
diagnostic accuracy: 10-60%
often NON-diagnostic
What are drawbacks of EUS ?
Including high-grade
atypical epithelial cells:
diagnostic in mucinous cysts
diagnostic accuracy: 80%
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
What are EUS features leading to consider surgery ?
Define mural nodule(s): 3-9 fold risk malignancy
Main duct features suspicious for involvement
Cytology: suspicious or positive for malignancy
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
EUS-FNA: Fluid Analysis in Cysts
Typ SCN MCN IPMN SPN Pseudocyst
Viscosity
Mucin
Amylase
CytologyCytology negative or
Glyogen-con-taining cuboid
cells
mucin-
containing column cells
papillary clusters of
mucin-column cells,
atypia
Branching papillae
cuboid or cylindric cells, high cellularity, myxoid stroma
«dirty material»
Macrophages,Inflammatory cell
Viscosity Low High High NA Low
Mucin Low High High NA Low
Amylase < 250 U/L < 250 U/L < 250 U/La Low High
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
CEA in Cyst-Fluid: What for ? Useful ?
Mucinous vs. Non-mucinous (serous)
Cut-off unclear: e.g. > 800 ng/mL
No correlation with risk of malignancy
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
How to perform surveillance for BD-IPMN and MCN?
< 1 cm:
1-2 cm:
2-3 cm:
> 3 cm:
CT/MRI in 2-3 years
Close surveillancealternating MRI with EUS every 3-6 monthsStrongly consider surgery (in young, fit patients)
EUS in 3-6 monthsLengthen interval, alternating EUS and MRIConsider surgery in young, fit patients (long surveillance)
CT/MRI yearly (for 2 years) lengthen interval if no change
Universitätsklinik für Viszerale Chirurgie und Medizin / www.chirurgiebern.ch
Which syndrome associates with multiple/oligocystic SCN ?
Hippel-Lindau-Syndrome