Gi -- Cystic Pancreatic Masses

Front 1

nowotwory torbielowate trzustki

Back 1

1) Serous cystadenoma



2) Mucinous cystic tumor



3) Intraductal papillary tumors



4) Rare tumors

Front 2

most classic type of serous cystadenoma

Back 2

microcystic serous cystadenoma
CT =>Mikrotorbiele (max do 2 cm) i włóknista blizna centralna; może wydawać się zmianą litą

MR- T2WI, bright peripherally because of the cysts. Dense central fibrous stroma
zmiana łagodna

Front 3

What is a variation in its appearance?

Back 3

Fibrous septae become so dense and the cysts so small that you cannot appreciate the cysts at all really. Lesion is always denser centrally. If you are going to see cysts, you will see them peripherally.

Front 4

microcystic serous cystadenoma -zwapnienia?

Back 4

20% of the time has CENTRAL calcification

Front 5

Where are the thin walled mucinous tumors located?

Back 5

Tail or other part of proximal pancreas (head is considered distal pancreas)

Front 6

Do thin walled mucinous tumors calcify?

Back 6

Yes
Calcify peripherally, just the opposite of serous cystadenomas.

Front 7

When you see a unilocular cystic mass in the proximal pancreas with thin wall and a single septation, what is your diagnosis?

Back 7

Benign mucinous tumor, probably cystadenoma.

Front 8

When you do see a unilocular mass with one or more nodules in the wall, what is the most likely diagnosis?

Back 8

MALIGNANCY, most commonly cystadenocarcinoma

Front 9

When the tumor originates in the main pancreatic duct, what is the significance?

Back 9

all are MALIGNANT invasive adenocarcinomas

Front 10

What is the sign of a main duct tumor?

Back 10

Dilatation of portion or all of main pancreatic duct.

Front 11

When you see dilatation of a duct and suspect tumor, what is the question you need to ask?

Back 11

Does the patient have history of chronic pancreatitis?
Absence of history of chronic pancreatitis, by history and imaging, strongly favors IPMT

Front 12

How is diagnosis of IPMT confirmed?

Back 12

ERCP

Front 13

What is behaviour of IPMT?

Back 13

As discussed before, all tumors of main pancreatic duct = MALIGNANT

Front 14

What do these tumors do to the duct?

Back 14

They infiltrate the duct, causing it to become markedly dilated and you can see nodularity of the tumor along the distended duct walls. The duct becomes distended with secretions as well as mucin produced by the tumor.

Front 15

Where are branch duct intraductal papillary mucinous tumors found?

Back 15

Most commonly in the uncinate process
Hypodense mass within the uncinate process.

Front 16

What do they look like?

Back 16

Unilocular masses

Front 17

How are they best diagnosed?

Back 17

They will usually fill on ERCP. However, sometimes the branch duct becomes obstructed by the mucinous tumor secretions, and thus may not be visualized on ERCP. Therefore, the best way to diagnose these lesions is now considered to be MRCP.

Front 18

Are branch duct IPMTs malignant?

Back 18

They can be.

Front 19

Are branch duct IPMTs really unilocular?

Back 19

No. May have small or large locules. But these are not readily visualized on imaging. Of course with high resolution imaging they can be, however.

Front 20

What is SPEN tumor?

Back 20

Solid papillary epithelial neoplasm

Front 21

Is SPEN more or less common than IPMTs?

Back 21

Less. An unusual lesion.

Front 22

When should you consider the diagnosis of SPEN tumor?

Back 22

Hypodense complex cystic to partially solid appearing pancreatic mass in a YOUNG WOMAN

Front 23

SPEN- Are they malignant?

Back 23

Locally aggressive, but do not metastasize

Front 24

So, when do you think of SPEN?

Back 24

Unilocular hypodense cystic or partially solid mass in the absence of pancreatitis in a WOMAN aged 18 - 30 (YOUNG).

Front 25

What is done with SPENs?

Back 25

RESECTED

Front 26

So, what is the tumor that is universally considered benign?

Back 26

Microcystic serous tumor

Front 27

When you are dealing with a mucinous cystic mass (cystadenoma), is it more likely benign or malignant?

Back 27

Most are benign (65%).


30% have potential to be locally invasive.


5% frankly malignant

Front 28

So, what is the appearance of the ones that are pretty much always benign?

Back 28

The appearance of mucinous cystadenoma that is almost univerally benign is the unilocular cystic mass with thin walls and a single thin septation.

Front 29

What are the features that make a unilocular pancreatic mass more likely malignant?

Back 29

1) Wall thick (thicker than 2mm), with or without nodules.

2) Peripheral calcifications

Front 30

What about IPMTs?

Back 30

All considered malignant (main duct) or premalignant (branch duct = uncinate), but premalignant ones often grow very slowly, and thus uncertain whether to resect or watch.

Front 31

What are the signs of IPMT malignancy?

Back 31

Solid mass

Main pancreatic duct dilated

Diffuse or multifocal involvement

Calcified intraluminal content

Front 32

When these lesions do go frankly malignant, what do they become?

Back 32

Invasive adenocarcinoma

Front 33

Basically, then:

Back 33

If you have a solid pancreatic mass, it is adenocarcinoma until proven otherwise, and out it comes.


But if you have a cystic pancreatic mass, there are many possibilities, and the lesion's characteristics need to be analyzed.

Front 34

What are criteria for pancreatic cystic tumor that can be followed?

Back 34

Lesion less than 2.5 cm

Lesion displays NO solid elements

There is no extension into the main pancreatic duct

Front 35

If you need to, how do you evaluate whether a lesion extends into the main pancreatic duct or is involving other duct?

Back 35

MRCP or ERCP

Front 36

What is another way to evaluate whether the lesion involves ducts? (actually, the first way it should be attempted?)

Back 36

Do multislice volume rendering of the area of interest. Basically gives you a 3-D slab that you can visualize more information on than single slice.

Front 37

DDx for cystic pancreatic mass:

Back 37

MOST CYSTIC PANCREATIC MASSES- PSEUDOCYSTS. HISTORY OF RECENT PANCREATITIS- MOST LIKELY PSEUDOCYST. CAN ALSO BE FOCAL PANCREATIC NECROSIS. AND CAN ALSO BE CYSTIC DYSTROPHY OF THE DUODENAL WALL, ALSO A SEQUELA OF PANCREATITIS.



Other possibilities: Choledochal cysts.

Duodenal diverticulum can masquerade as pancreatic mass! All you gots to do is a GI if you are worried about this.

Duplicaton cyst of the duodenum.


Rare tumors (adenosquamous)


Mets (melanoma)


Malignant GIST tumor of adjacent stomach

Front 38

What are the types of choledochal cyst?

Back 38

1 to 5

Front 39

choledochal cyst
What is type 1?

Back 39

Fusiform dilatation of the common duct

Front 40

choledochal cyst
What is type 2?

Back 40

Diverticulum off of the common duct

Front 41

choledochal cyst
Type 3?

Back 41

Choledochocele -- intraduodenal diverticulum off of the CBD

Front 42

choledochal cyst
Type 4?

Back 42

Dilated common duct and intrahepatic cysts

Front 43

choledochal cyst
Type 5?

Back 43

Caroli disease -- Multiple intrahepatic cysts

Front 44

Most important points:

Back 44

1) Classic microcystic serous cystadeno is benign

2) When you have unilocular mass, most common entities are NOT EVEN NEOPLASMS

3) When basic non-neoplastic entities ruled out, determine whether the lesion is peripheral or ductal.

4) If it is peripheral, consider patient age/sex. If young woman, SPEN. If not, evaluate wall thickness/nodularity and wall calcification. If present, resect. If not, look at overall size. If small (2.5 cm or less) watch it. If it grows in 3-6 months, resect.

5) If ductal, evaluate whether main duct involved or just branch duct. If main duct involved, resect. If just branch duct (most common location uncinate process), evaluate size of lesion. If under 2.5 cm, consider follow up in 3-6 months. If growth, resect.