Pancreatic Cystic LesionsPancreatic Cystic LesionsA semiA semi--interactive tutorialinteractive tutorial

Running time approx: 15 Running time approx: 15 minsmins

David Gellis (HMSIII)Radiology Core RotationBIDMC

Match the patient with their presentation:Match the patient with their presentation:Quiz 1

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A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. Asymptomatic 67 y.o M c/ abnormality detected incidentally on CT abdomen

C. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

Quiz 1

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

C. Asymptomatic 67 y.o c/ abnormality detected incidentally on CT abdomen

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Axial C+ CT PACS, BIDMC

#1

Quiz 1

1 2

3

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. Asymptomatic 67 y.o M c/ abnormality detected incidentally on CT abdomen

C. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

Match the patient with their presentation:Match the patient with their presentation:

Quiz 1

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

C. Asymptomatic 67 y.o c/ abnormality detected incidentally on CT abdomen

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3

Axial C+ CT. PACS, BIDMC

#2

Match the patient with their presentation:Match the patient with their presentation:Quiz 1

1 2

3

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. Asymptomatic 67 y.o M c/ abnormality detected incidentally on CT abdomen

C. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

Match the patient with their presentation:Match the patient with their presentation:Quiz 1

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

C. Asymptomatic 67 y.o c/ abnormality detected incidentally on CT abdomen

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3

#3

Coronal C+ CT. PACS, BIDMC Courtesy C. Vollmer

#3

Match the patient with their presentation:Match the patient with their presentation:Quiz 1

1 2

3

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. Asymptomatic 67 y.o M c/ abnormality detected incidentally on CT abdomen

C. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

AnswersAnswersQuiz 1

A. 45 y.o M c/ hx of ETOH abuse and recent episode of 10/10 epigastic abdominal pain.

B. Asymptomatic 67 y.o M c/ abnormality detected incidentally on CT abdomen

C. 76 y.o F c/ 2 wk hx of n/v, 12 lb wt loss, abnormality detected on CXR.

A: Pseudocyst C: Mucinous cystadenoca.B: Side-branch IPMN

Quiz 1 Answers continuedQuiz 1 Answers continued

We will go over the characteristic features that We will go over the characteristic features that may help distinguish these lesions in the slides may help distinguish these lesions in the slides to come.to come.Its important to note however that in real life we Its important to note however that in real life we are presented with clinical histories in are presented with clinical histories in conjunction with imagingconjunction with imagingIndeed, this clinical history and Indeed, this clinical history and followupfollowup is often is often key as the appearance of cystic lesions can key as the appearance of cystic lesions can confuse even trained professionals.confuse even trained professionals.

GoalsGoals

To review the differential diagnosis of To review the differential diagnosis of cystic lesions of the pancreas.cystic lesions of the pancreas.To review the menu of tests available to To review the menu of tests available to aide in diagnosis.aide in diagnosis.To review the characteristic findings of To review the characteristic findings of these lesions (especially on CT)these lesions (especially on CT)To present an algorithm for workup of To present an algorithm for workup of lesionslesions

RationaleRationale

Cystic lesions are increasingly being Cystic lesions are increasingly being picked up incidentallypicked up incidentally30% of pancreatic resections at MGH are 30% of pancreatic resections at MGH are now for cystic lesions.now for cystic lesions.11

Imaging plays an evolving role in the Imaging plays an evolving role in the workup and management of these lesions.workup and management of these lesions.

1 Brugge et al

DdxDdx of cystic lesionsof cystic lesionsNonNon--neoplasticneoplastic cystic lesionscystic lesions–– PseudocystPseudocyst (~90% of all cystic masses in panc)(~90% of all cystic masses in panc)11

–– Congenital cysts (AKPD, VHL, CF, true cyst)Congenital cysts (AKPD, VHL, CF, true cyst)Cystic Cystic NeoplasmsNeoplasms (10(10--15% of cystic masses)15% of cystic masses)22

–– Serous Serous cystadenoma/adenocacystadenoma/adenoca (32(32--39% of CNs)39% of CNs)22

–– MucinousMucinous cystadenoma/adenocacystadenoma/adenoca (10(10--45% of 45% of CNsCNs) ) –– IntraductalIntraductal papillary papillary mucinousmucinous neoplasm neoplasm (21(21--33% of 33% of CNsCNs))

Main duct vs. sideMain duct vs. side--branchbranch–– Cystic degeneration of solid tumor including endocrine Cystic degeneration of solid tumor including endocrine

tumors tumors (<10% of (<10% of CNsCNs).).

NonNon--pancreatic lesionspancreatic lesions

1. Figueriras 2. Brugge

Definitions: Definitions: PseudocystPseudocyst

Complication of acute pancreatitisComplication of acute pancreatitisOrganization of fluid collection c/ cystOrganization of fluid collection c/ cyst--like like wall (no true epithelium).wall (no true epithelium).May be hemorrhagic, walls may calcify, May be hemorrhagic, walls may calcify, more often shrinks over time.more often shrinks over time.Some semiSome semi--characteristic radiological characteristic radiological features, but emphasis is on clinical features, but emphasis is on clinical hxhx..

Characteristics of Cystic Characteristics of Cystic NeoplasmsNeoplasmsDemographicsDemographics PathologyPathology FluidFluid LocationLocation 1. Malignancy1. Malignancy

2. Prognosis2. Prognosis

SCASCA Middle aged Middle aged female>male. female>male. No No h/oh/o pancreatitispancreatitis

CuboidalCuboidal glycogen richglycogen rich

Thin, Thin, serousserous

Evenly Evenly distributeddistributedNo No relnreln to to PDPD

1. 1. RarelyRarely 2. Resection 2. Resection curativecurative

MCNMCN Middle aged, Middle aged, mostly female. mostly female. No No h/oh/o pancreatitispancreatitis

Columnar, Columnar, ovarianovarian--like like stromastroma

Thick, Thick, mucinmucin

Body/ Tail Body/ Tail No No relnreln to to PDPD

1. 1. ModerateModerate 2. Resection 2. Resection curative as long as curative as long as no invasionno invasion

IPMNIPMN Elderly male. Elderly male. OccOcc h/oh/o pancreatitis.pancreatitis.

CytologicallyCytologically similar to similar to MCN, no MCN, no ovarianovarian--like like stromastroma

Thick, Thick, mucinmucin

Head Head Growing Growing within/out within/out of PDof PD

1. 1. HighHigh (main (main duct), duct), LowLow (side(side-- branch)branch) 2. Resection 2. Resection curative for </= curative for </= borderline borderline atypiaatypia

SCA= serous cystadenoma; MCN= mucinous cystic neoplasm; IPMN= intraductal papillary mucinous neoplasm. Adapted from Brugge, Oh

The Big PictureThe Big Picture

1.1. Is lesion in pancreas?Is lesion in pancreas?2.2. PseudocystPseudocyst vs. vs. neoplasmneoplasm??3.3. SCA SCA vsvs MCN/IPMNMCN/IPMN

1.1. If IPMN, location?If IPMN, location?4.4. Evidence of malignancy, invasion, Evidence of malignancy, invasion,

metastatic diseasemetastatic disease

Adapted from Oh et al

Menu of Radiologic TestMenu of Radiologic Test

CTCTMRI/MRCPMRI/MRCPEUS/ EUS + FNAEUS/ EUS + FNAERCPERCP

CT ImagingCT ImagingIndications: Core modality for Indications: Core modality for DxDx, surgical , surgical planning, planning, followupfollowup of some lesions. Often seen of some lesions. Often seen first as incidentals on CT.first as incidentals on CT.Can describe cystsCan describe cysts–– Location, sizeLocation, size–– LocularityLocularity ((unilocularunilocular vs. vs. oligolocularoligolocular vs. vs. multilocularmultilocular))–– Size of cysts (Size of cysts (microcystsmicrocysts <2mm, <2mm, macrocystsmacrocysts, ,

““honeycombhoneycomb””–– Wall thicknessWall thickness

Some findings are characteristic. However these Some findings are characteristic. However these are seen in minority of exams.are seen in minority of exams.–– Accuracy of CT ranges from 20Accuracy of CT ranges from 20--90% depending on 90% depending on

study!! (Oh)study!! (Oh)

Other modalitiesOther modalitiesERCP:ERCP:–– GoldGold--standard for determining communication c/ PD (for standard for determining communication c/ PD (for

diagnosing diagnosing IPMNsIPMNs))MRI/MRCPMRI/MRCP–– Communication c/ PD (as ERCP), while simultaneously imaging Communication c/ PD (as ERCP), while simultaneously imaging

parenchyma and cystparenchyma and cystEUSEUS–– Better delineation of internal structures (Better delineation of internal structures (septationseptation, mural , mural

nodules, wall), nodules, wall), parenchymalparenchymal changeschanges–– Variable claims re: accuracy Variable claims re: accuracy

EUS + FNAEUS + FNA–– Cytology is most accurate method of Cytology is most accurate method of dxdx, though limited by ability , though limited by ability

to get cells (to get cells (senssens <50%) (Oh et al)<50%) (Oh et al)–– Amylase (Amylase (elevelev in IPMN, in IPMN, pseudocystpseudocyst) and tumor markers (CEA)) and tumor markers (CEA)–– Indicated where will change management (more later)Indicated where will change management (more later)

Our Pt #1: Our Pt #1: PseudocystPseudocyst on CTon CTCharacteristic Characteristic unilocularunilocular cyst (cyst (CC) c/ thick wall in ) c/ thick wall in tail of pancreastail of pancreasEvidence of pancreatitis Evidence of pancreatitis is key: is key: edematous pancreas(edematous pancreas(**), ), fat stranding (fat stranding (##): ): Other features:Other features:

–– SeptationsSeptations unusualunusual–– May mimic May mimic MCNsMCNs

Axial C+ CT. PACS, BIDMC

Our Pt #1: Development Our Pt #1: Development Of Of PseudocystPseudocyst on CTon CT

Organization of fluid collection . Axial C+ CT images, 1 month apart. PACS, BIDMC.

Serous Serous CystadenomaCystadenoma

Classically:Classically:–– MicrocysticMicrocystic or or ““honeyhoney--combedcombed””–– Central calcifications, scarCentral calcifications, scar–– Thin Thin septaeseptaeActually:Actually:–– 20% 20% macrocysticmacrocystic–– Borders b/w Borders b/w microcystsmicrocysts indistinct on CTindistinct on CT–– Above features relative rareAbove features relative rare

Axial C+ CT. Finding: # microcystic, multilocular lesion c/ central enhancing scar. PACS, BIDMC. Courtesy of Mara Barth

Companion Patient: Serous Cystadenoma on CT

Central scar and calcification in SCA. Figueiras Curr Probl Diagn Radiol, Sept 2007

Another Companion Patient: Serous Cystadenoma on CT

EUS c/ doppler: Multiloculated microcystic lesion abutting aorta (A). PACS, BIDMC. Courtesy of Mara Barth

Companion Patient: Serous Cystadenoma on EUS

Coronal HASTE MRI: Clustered microcytic lesion in uncinate process. PACS, BIDMC. Courtesy of Mara Barth

Companion Patient: Serous Cystadenoma on MRI

MucinousMucinous CystadenomaCystadenoma

MacrocysticMacrocysticPeripheral calcificationsPeripheral calcificationsMalignant lesions often c/ thick Malignant lesions often c/ thick walls/walls/septationsseptationsMural nodule or solid components Mural nodule or solid components suggestive of malignant degenerationsuggestive of malignant degenerationHi signal on T1 or T2 MRIHi signal on T1 or T2 MRI

PACS, BIDMC

Our Pt #2: MCN on CTCoronal C+ CT:• Large thick walled,

macrocystic lesion in tail of pancreas (C).

• Solid components, mural nodules indicating potential malignancy

EUS: Cyst c/ mural nodule (N). GICare Endoscopy, BIDMC

Our Pt #2: MCN on EUS

Patient 2: OutcomePatient 2: OutcomeFNA of lesion nonFNA of lesion non--diagnostic.diagnostic.Preoperative high suspicion for Preoperative high suspicion for mucinousmucinous adenocarcinomaadenocarcinoma given imaging appearance. No given imaging appearance. No evidence of metastatic disease. Distal evidence of metastatic disease. Distal pancreatectomypancreatectomy planned.planned.At surgery, lesion was grossly invasive of colon. Several At surgery, lesion was grossly invasive of colon. Several areas suspicious for metastatic disease. areas suspicious for metastatic disease. distal distal pancreatectomypancreatectomy, , cholecystectomycholecystectomy, , splenectomysplenectomy and and partial partial colectomycolectomy..Pathology: Pathology: mucinousmucinous cystadenocarcinomacystadenocarcinoma..PostPost--op course: developed op course: developed metsmets to peritoneum and lung to peritoneum and lung which progressed despite 6 cycles chemotherapy. At 6 which progressed despite 6 cycles chemotherapy. At 6 months postmonths post--op, the patient elected for hospice care.op, the patient elected for hospice care.

Companion Pt:Companion Pt: Main Duct IPMN Main Duct IPMN

On CTOn CTSeen growing off/out Seen growing off/out of main PD (of main PD (CC).).Associated c/ dilation Associated c/ dilation of PD (seen here) and of PD (seen here) and filling defects (not filling defects (not seen) 2/2 mural seen) 2/2 mural nodules.nodules.MucinMucin at at ampullaampulla on on endoscopy is endoscopy is diagnosticdiagnostic

Axial C+ CTs. PACS, BIDMC. Courtesy C. Vollmer

EUS: Dilated PD (top); intramural filling defect (#) (right).PACS, BIDMC Courtesy C. Vollmer

Companion Pt: Companion Pt: Main Duct Main Duct

IPMN on EUSIPMN on EUS

Companion to Pt #3: Side-branch IPMNs

“Grape-like multilocular” lesion at panc head c/ communication

Counter-clockwise--Axial C+ CT: cluster of cysts; ERCP: contrast-filling cystic lesion in communication c/ PD; MRCP: enhancing cystic lesion in communication c/ PD.

Images: Oh et al.

Management AlgorithmsManagement Algorithms

Oh et al.

Figueiras et al

ThanksThanks

SadhnaSadhna NandwanaNandwanaMara BarthMara BarthCharles VollmerCharles VollmerGillian LiebermanGillian Lieberman

ReferencesReferencesBruggeBrugge, WR. Current Concepts: Cystic , WR. Current Concepts: Cystic NeoplasmsNeoplasms of the of the Pancreas. NEJM 2004; 351;12: 1218Pancreas. NEJM 2004; 351;12: 1218--1226.1226.

Demos, TC. Pictorial Review: Cystic Lesions of the Demos, TC. Pictorial Review: Cystic Lesions of the Pancreas. AJR 2001; 179: 1375Pancreas. AJR 2001; 179: 1375--13881388

Oh, HC. Cystic Lesions of the Pancreas: Challenging Oh, HC. Cystic Lesions of the Pancreas: Challenging Issues in Clinical Practice. Am J Issues in Clinical Practice. Am J GastroenterolGastroenterol 2008; 2008; 103:229103:229--239.239.

Figueiras,RGFigueiras,RG. The Spectrum of Cystic Masses of the . The Spectrum of Cystic Masses of the Pancreas: Imaging Features and Diagnostic Difficulties. Pancreas: Imaging Features and Diagnostic Difficulties. CurrCurr ProblProbl DiagnDiagn RadiolRadiol 2007;36: 1992007;36: 199--212.212.