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pancreatic cyst

Etiology: - idiopathic - von Hippel-Lindau disease - may be associated with pancreatitis or simply diagnosed after an episode of pancreatitis* * only pancreatic pseudocyst mentioned in ref [3] after episode of pancreatitis Epidemiology: - prevalence may be up to 20% in general population [3] - 1% at age 40, 9% at age 80 years [6] - mucin-producing pancreatic cysts occur almost exclusively in women (>98%) [3] Pathology: - true cyst with epithelial lining, containing - pool of pancreatic fluid - semisolid matter made up of debris or necrotic tissue - mucinous cystic neoplasms* [3] - found in the pancreatic body or tail in 90% of cases [3] - intraductal papillary mucinous neoplasms [3] - may involve the main pancreatic duct, its branches or both [3] - malignant potential is low - less hazzardous than pancreatic pseudocyts * non-mucin producing cysts have no malignant potential [3] Clinical manifestations: - frequently asymptomatic - abdominal pain with radiation to the back - nausea/vomiting - abdominal bloating Laboratory: - CA 19-9 may be a useful serum tumor marker - cystic fluid analysis - CEA in body fluid is high in mucinous adenomas - amylase in body fluid is high if pseudocyst & low to variable in adenomas Special laboratory: - abdominal ultrasound - endoscopic ultrasound with fine neeedle aspiration (EU-FNA) of cyst to rule out mucinous adenocarcinoma - indicated for cysts >= 2 high-risk features - size >= 3 cm - dilated main pancreatic duct - associated solid component [7] - not recommended in patients with imaging characteristic of resectable pancreatic cancer; surgical resection recommended prior to histopathology for diagnosis [3] - not indicated for pancreatic pseudocyst - endoscopic cytology & biopsy - percutaneous fine-needle biopsy/aspiration - positive mucin stain &/or elevated CEA in aspirated fluid suggests mucinous adenocarcinoma Radiology: - computed tomography of the abdomen - pancreatic cysts detected incidentally on abdominal CT - cysts with characteristics of serous cystadenomas (multicystic, lobulated structures resembling a bunch of grapes, with or without calcification) have no malignant potential & need no surveillance (see below - cysts with risk features should be evaluated with magnetic resonance cholangiopancreatography (MRCP) before determining risk profile for further surveillance [9] - ref [11] suggests you cannot determine risk features from non-pancreatic abdominal CT, thus apparently all pancreatic incidentomas need MRCP - surveillance with MRI for cysts without high-risk features* at 1 year, then every 2 years for 5 years if cyst is not changing [7,9] * see above (endoscopic ultrasound) for high-risk features Differential diagnosis: - pancreatic cancer - mucinous adenocarcinoma - cystadenocarcinoma (generally painful) - benign pancreatic cystadenoma (generally painless) - wall-off pancreatic necrosis - pancreatic pseudocyst - differentiating pancreatic cysts from pancreatic pseudocysts can be difficult because there is no definitive test with high sensitivity & specificity [3] - only pancreatic pseudocyst mentioned in ref [3] after episode of pancreatitis Complications: - infection leading to pancreatic abscess - biliary obstruction - portal hypertension - less likely to rupture than pancreatic pseudocyts - malignant transformation (pancreatic cancer) 0.03% [6] - most pancreatic cysts never become malignant* [3] - increase in size (27%) - delayed growth after 1, 2, or 3 years of initial stability 11%, 6%, & 1.5%, respectively - within 4.8 years, 1 of 259 patients died from a pancreatic cancer that developed at a site distant from cyst [8] - a second patient's cyst enlarged into an intraductal papillary mucinous neoplasm with high-grade dysplasia* [8] * exception is intraductal papillary mucinous neoplasms involving the main pancreatic duct [3] Management: - observation if asymptomatic - cyst drainage - endoscopic drainage - percutaneous catheter drainage - surgical drainage - laparoscopy vs open surgery - surgical resection for cysts with both a solid component & a dilated pancreatic duct or if EU-FNA results suggests malignancy [7] - surveillance after surgical resection in patient with invasive cancer or high-grade dysplasia in resected cyst [7]

Related

pancreatic necrosis pancreatic pseudocyst

General

cyst pancreatic disease

References

  1. Cleveland Clinic: Pancreatic Cysts and Pseudocysts http://my.clevelandclinic.org/disorders/pancreatitis/hic-pancreatic-cysts-and-pseudocysts.aspx
  2. Walsh RM, Vogt DP, Henderson JM, Zuccaro G, Vargo J, Dumot J, Herts B, Biscotti CV, Brown N. Natural history of indeterminate pancreatic cysts. Surgery. 2005 Oct;138(4):665-70; discussion 670-1. PMID: 16269295
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  4. Ferrone CR, Correa-Gallego C, Warshaw AL et al Current trends in pancreatic cystic neoplasms. Arch Surg. 2009 May;144(5):448-54 PMID: 19451487
  5. Weinberg BM, Spiegel BM, Tomlinson JS, Farrell JJ. Asymptomatic pancreatic cystic neoplasms: maximizing survival and quality of life using Markov-based clinical nomograms. Gastroenterology. 2010 Feb;138(2):531-40 PMID: 19818780
  6. Gardner TB et al. Pancreatic cyst prevalence and the risk of mucin-producing adenocarcinoma in US adults. Am J Gastroenterol 2013 Oct; 108:1546 PMID: 24091499 http://www.nature.com/ajg/journal/v108/n10/full/ajg2013103a.html
  7. Scheiman JM, Hwang JH, Moayyedi P American Gastroenterological Association technical review on the diagnosis and management of asymptomatic pancreatic neoplastic cysts. Gastroenterology 2015 Apr; 148:824 PMID: 25805376 - Vege SS, Ziring B, Jain R, Moayyedi P American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic pancreatic neoplastic cysts. Gastroenterology 2015 Apr; 148:819. PMID: 25805375
  8. Brook OR et al. Delayed growth in incidental pancreatic cysts: Are the current American College of Radiology recommendations for follow-up appropriate? Radiology 2016 Mar; 278:752. PMID: 26348231
  9. NEJM Knowledge+ Question of the Week. May 29, 2018 https://knowledgeplus.nejm.org/question-of-week/1833/
  10. Ayoub F, Davis AM, Chapman CG. Pancreatic Cysts - An Overview and Summary of Society Guidelines, 2021. JAMA. 2021;325(4):391-392. Jan 26 PMID: 33496762 https://jamanetwork.com/journals/jama/fullarticle/2775431
  11. NEJM Knowledge+ Complex Medical Care