Pancreas Cyst

ERIC TRAWICK
EUS CONFERENCE
JUNE 2011
 Overview

Pancreatic cysts are being diagnosed with increasing frequency

due to the widespread use of cross-sectional imaging
 Estimated prevalence of 1% in the general population
 Up to 40% are asymptomatic
Pancreatic cysts can be divided into 2 broad categories
 Neoplastic
 Classified by the type of epithelium lining the cyst
 Non-neoplastic
 Pseudocyst
 Non-neoplastic pancreatic cysts (rare)
 Include retention cyst & True cysts
 Retention cysts
 Mucinous non-neoplastic cysts
 Lymphoepithelial cysts
Accurate cyst categorization is needed for proper management

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-

309.
 Overview

• Rarely, solid pancreatic tumors may present as

pancreatic cyst
– Islet cell tumor
• Pancreatic cystic lesions are usually an isolated
finding, but are associated with both von Hippel-
Lindau disease and ADPKD
– Pancreatic cyst are present in up to 70% of patients with von
Hippel-Lindau disease
– Approximately 10% of patients with ADPKD have pancreatic
cyst

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-

309.
 Cross-sectional Imaging

• Unreliable means of diagnosis when used alone

• Up to 40% of serous and mucinous lesions are
misdiagnosed as pseudocysts
• Diagnostic accuracy of CT is reported between 20-
83%
• MRI is equivalent or slightly better than CT for
diagnosis of cystic pancreatic lesions
• As expected MRCP is superior to CT in defining
ductal anatomy

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-

309.
Journal of Computer Assisted
Tomography. 1999 23(6):906-912.
 Indication for EUS

No hard and fast rules

Will EUS change management?
 Symptomatic or worrisome lesions are usually resected
without need for EUS &/or FNA
Is there a clear history of pancreatitis and a new
cystic lesion?
 If obviously a pseudocyst then don’t need EUS
EUS +/- FNA is indicated to further assess and
categorize cystic pancreatic lesions

World J Surg (2008) 32:2028–2037

 EUS Morphology

• Cyst wall
– Thick vs. thin

• Solid component
• Associated with malignancy
• Septations
– Micro vs. macrocystic

• Ductal abnormalities
• Main duct vs. side duct
• Number of cyst
• Lymphadenopathy
• EUS morphology can correctly differentiate mucinous from
non-mucinous cystic lesions approximately 50% of the time

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-

309.
Normal Pancreas—
EUS image of the normal pancreas (P, outlined by short arrows) with a finely granular echoic
pattern that is characteristically very homogeneous. A part of the normal diameter (1 mm)
pancreatic duct (pd) is seen in the tail. Upper pole of the kidney (K) is also visible. (Magnification
range scale = 9 cm).
JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-
309.
 Examples of Morphology

JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-

309.
JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-
309.
JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-
309.
JOP. J Pancreas (Online) 2010 Jul 5; 11(4):299-
309.
 FNA & Fluid Analysis

Cytology
 High specificity, low sensitivity
Mucin
 High specificity, low sensitivity
Amylase/Lipase
 Elevated in Pseudocyst & IPMNs
 Low in SCN & MCN
CEA
 Most accurate test to distinguish mucinous from non-mucinous
cyst
DNA analysis
 Mixed data when compared to CEA
World J Surg (2008) 32:2028–2037
Cyst Fluid Analysis

ASGE Guidelines 2005

 Application
 A retrospective analysis of 153 pts undergoing EUS for pancreatic cyst between 1996 to 2007
 Clinical history, EUS characteristics, cytology, tumor markers and surgical histology were
collected
 Predictors of malignancy were determined by univariate and multivariate analysis

Aliment Pharmacol Ther. 2010 Jan 15;31(2):285-

94
 Application

 Prospective study of 341 pts found to have a pancreatic cystic lesion >10 mm on abd
imaging
 Exclusion criteria included: abnormal coags/platelets &/or an abscess
 EUS was performed looking at morphology, cyst fluid cytology, and cyst fluid tumor
markers (CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3)

Gastroenterology. 2004 May;126(5):1330-6

Gastroenterology. 2004 May;126(5):1330-6
 Summary

No single test or imaging modality can reliably

differentiate cyst type
Composite data is needed
 Clinical features of the patient
 Cross-sectional imaging
 Tumor markers
 EUS with cyst fluid analysis
 http://daveproject.org/pancreas-chronic-pancreatitis-w
ith-eus-fna-of-pseudocyst/2004-05-07/
 http://daveproject.org/pancreas-eusfna-of-ipmn-with-m
alignant-transformation/2007-11-13/
ASGE Guidelines 2005
 http://daveproject.org/pancreas-serous-cyst-with-bleeding/2009-0
4-23/
 http://daveproject.org/pancreas-serous-cystadenoma-with-fna/2007
-11-13/
ASGE Guidelines 2005
 http://daveproject.org/eus-fna-of-solid-pseudopapillary-tumor/201
GASTROENTEROLOGY 2005;128:463–469