Cystic pancreatic neoplasms
© International Cancer Imaging Society 2003
Accepted: 5 November 2002
Published: 5 May 2015
Cystic pancreatic neoplasms are uncommon, but are being seen more frequently due to the widespread use of cross-sectional imaging. In this article, we will address the clinical and imaging features of the more commonly seen neoplasms. Points of differentiation between these neoplasms, the use of cyst fluid analysis and an approach to the incidentally discovered cystic mass will be addressed.
KeywordsPancreas CT cysts MR neoplasms pancreatic ducts
serous neoplasms cystadenoma/adenocarcinoma
solid pseudo-papillary epithelial neoplasm
Von-Hippel Lindau disease
cystic islet cell neoplasms
giant cell neoplasm.
serous cystic neoplasms
mucinous cystic neoplasms
intraductal papillary mucin-producing neoplasms
other less common neoplasms.
The following discussion will be restricted to the more common neoplasms.
Serous cystic neoplasms
Mucinous cystic neoplasm (MCT)
Imaging differences between serous and mucinous cystic neoplasms
Johnson et al. reported a classification scheme which is of some use in distinguishing between serous and mucinous neoplasms. Useful criteria include the number of cysts (less than six in MCT neoplasm, greater than six in serous cystic neoplasm) and size of the majority of cysts (greater than 2 cm in MCT neoplasm and less than 2 cm in serous cystic neoplasm). Using these criteria, an accuracy rate of 70–80% was achieved in distinguishing the benign serous from the malignant mucinous neoplasms.
However, a more recent study of 100 cystic neoplasms (excluding pseudocysts) by Procacci et al. found that accurate characterisation was possible in only 60% of neoplasms. In general, serous neoplasms were more accurately diagnosed than mucinous neoplasms. 15–20% of neoplasms were incorrectly diagnosed due to the overlap of imaging features. Curry et al. also reported low accuracy rates when readers were asked to classify cystic neoplasms into serous or mucinous categories.
Intraductal papillary mucinous or mucin-producing neoplasm (IPMT)
Considered to be a relatively new entity, IPMT represents a spectrum of a neoplastic process, which has been previously referred to by a variety of terminology. Controversy remains as to the exact nature of the neoplasm, its biology and also its management and treatment. However, there are some distinct cross-sectional imaging characteristics that correlate well with the documented endoscopic retrograde cholangiopancreatography (ERCP) findings. These include a markedly dilated pancreatic duct, excessive mucin secretion and bulging papilla.
main duct type
side branch or branch duct type.
Main duct type
Side branch type
The main duct type of IPMT is thought to be more malignant and requires surgical treatment in the form of a total or subtotal pancreatectomy. In contrast, side branch neoplasms are thought to be less aggressive and can be either observed or resected with a Whipple procedure. The prognosis for the side branch type neoplasms is excellent in contrast to that for the main duct type, which if invasive can be similar to that for ductal adenocarcinoma.
Solid pseudo-papillary epithelial neoplasms
Aspiration biopsy and cyst fluid analysis of cystic neoplasms
There are data suggesting that differentiation between the benign and malignant cystic neoplasms may be achieved with high sensitivity, based on analysis of the cyst fluid for carcino-embryonic antigen (CEA) and other neoplastic markers such as CA-129 as well as amylase levels[20,21]. The CEA and other neoplasm marker levels are high in the malignant cystic neoplasms and low in the pseudocysts and in the serous cystic neoplasms.
Histological analysis of fine-needle aspiration (FNA) biopsy is fraught with problems, as the lining epithelium of the serous and cystic neoplasms can be incomplete and/or heterogeneous; thus a biopsy at one site may not be a true representation of the neoplasm type.
Incidental ‘cystic lesions’ in asymptomatic patients
Due to the widespread use of imaging, small 1–3 cm cystic masses in the pancreas are being more commonly seen in asymptomatic individuals. As true epithelial cysts of the pancreas are extremely rare, these are a diagnostic problem. Some believe that they may represent side duct intraductal neoplasms, and recommend follow-up to ensure stability. An ERCP or MRCP may also prove the true nature of the lesion by demonstrating a communication with the pancreatic duct, which is characteristic of an IPMT. If these lesions are being managed conservatively and followed with serial imaging, surgical resection should be performed if there is any change in size or internal features.
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