Cross-sectional imaging often reveals unexpected pancreatic cystic lesions, it is a frequent clinical problem, Should we observe or remove it? What's the diagnosis? Is our patient in danger of malignancy?
Don’t miss this @aegastro @my_ueg #EducAEG #UEGambassador twitter thread
Importance of Pancreatic Cystic Neoplasms (PCN):
Most are asymptomatic at diagnosis, frequency increases with age
Symptoms: acute pancreatitis (Wirsung obstructed by the cyst or mucus), pain, obstructive chronic pancreatitis, jaundice
> symptoms, >malignancy risk!
Classification of PCN:
Mucinous: intraductal papillary mucinous neop. and mucinous cystic neop.
Nonmucinous: serous cystic neoplasm, solid pseudopapillary neoplasm and cystic neuroendocrine tumours
Endoderm- derived columnar epithelium is characteristic for mucinous lesions
👇
Intraductal papillary mucinous neoplasms (IPMN)
Characterized by papillary proliferation+mucus production. It may involve Wirsung (becomes dilated) and/or branch ducts (cysts connected to the ductal system). It may evolve to pancreatic cancer particularly if Wirsung is involved
Intraductal papillary mucinous neoplasms (IPMN)Characterized by papillary proliferation+mucus production. It may involve Wirsung (becomes dilated) and/or branch ducts (cysts connected to the ductal system). It may evolve to pancreatic cancer particularly if Wirsung is involved
Intraductal papillary mucinous neoplasms (IPMN)Characterized by papillary proliferation+mucus production. It may involve Wirsung (becomes dilated) and/or branch ducts (cysts connected to the ductal system). It may evolve to pancreatic cancer particularly if Wirsung is involved
IPMN subtypes :
Intestinal: main duct, head, 40%->coloid/tubular adenoca
Pancreatobiliary: main duct,head, 68%->tubular adenoca
Oncocytic: rare, nodules,50%-> coloid/tubular adenoca
Gastric: most frequent, branch-type, uncinate, 10%->tubular adenoca https://www.nature.com/articles/s41575-019-0195-x
Diagnosis and management of pancreatic cystic neoplasms: current evidence and guidelines

Pancreatic cystic neoplasms are a heterogeneous group of pancreatic cysts with different biological behaviours and variable risk of progression to malignancy. This Review summarizes the latest...

https://www.nature.com/articles/s41575-019-0195-x
IPMN: risk factors for malignancy
Main duct involvement (60% in resected specimens vs 10 to 30% in resected side branch IPMNs), specially>1cm
Contrast-enhanced mural nodules
Size>3-4cm
Symptoms
Pts at risk of PDAC even in other regions of the gland without involvement
👇👇👇
Intraductal papillary mucinous neoplasms -> management: follow these guidelines:
European guidelines 2018 @Gut_BMJ @chiaro_del @MarcBesselink https://doi.org/10.1136/gutjnl-2018-316027
Fukuoka 2017 @pancreatology@SalviaRobi https://www.sciencedirect.com/science/article/pii/S1424390317305161?via%3Dihub
Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas

The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN…

https://doi.org/10.1136/gutjnl-2018-316027
Mucinous Cystic Neoplasms (MCN)
Characterized by mucinous epithelium and ovarian-type stroma, in body/tail
It is described as macrocystic, septated cyst with small number of cavities, it may have eccentric calcifications, no connection to ductal system
95% women, 5-7th decades
MCN:
>risk malignancy:
≥5cm
Nodules/mass
Thickened/irregular Wall
Calcifications
Management of MCN according to the European guidelines: a conservative approach is recommended for asymptomatic MCN measuring <40 mm without an enhancing nodule
https://doi.org/10.1136/gutjnl-2018-316027
@chiaro_del @MarcBesselink @Gut_BMJ
European evidence-based guidelines on pancreatic cystic neoplasms

Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas,...

https://doi.org/10.1136/gutjnl-2018-316027
Serous cystic neoplasm (SCN). Cuboidal epithelium without dysplasia
70% women, 5-7th decades, NON-MUCINOUS solitary lesion
Classic SCN is microcystic (multiple small cysts, honeycomb-like) but can be macrocystic or solid. A central scar or calcification can be present
Serous cystic neoplasm (SCN). Cuboidal epithelium without dysplasia70% women, 5-7th decades, NON-MUCINOUS solitary lesionClassic SCN is microcystic (multiple small cysts, honeycomb-like) but can be macrocystic or solid. A central scar or calcification can be present
Serous cystic neoplasm (SCN). Cuboidal epithelium without dysplasia70% women, 5-7th decades, NON-MUCINOUS solitary lesionClassic SCN is microcystic (multiple small cysts, honeycomb-like) but can be macrocystic or solid. A central scar or calcification can be present
Serous cystic neoplasm (SCN). Cuboidal epithelium without dysplasia70% women, 5-7th decades, NON-MUCINOUS solitary lesionClassic SCN is microcystic (multiple small cysts, honeycomb-like) but can be macrocystic or solid. A central scar or calcification can be present
Serous cystic neoplasm (SCN). Cuboidal epithelium without dysplasia70% women, 5-7th decades, NON-MUCINOUS solitary lesionClassic SCN is microcystic (multiple small cysts, honeycomb-like) but can be macrocystic or solid. A central scar or calcification can be present
SCN management: remove only if symptoms, for example this case from @Dhgua, the patient had jaundice due to a a massive SCN, a Whipple procedure was performed
Cystic neuroendocrine tumor
It is a pancreatic NET with a central cystic changes. Solitary lesion, 5-6th decades, frequently with wall contrast enhancement, 10% malignant potential
Cystic neuroendocrine tumor It is a pancreatic NET with a central cystic changes. Solitary lesion, 5-6th decades, frequently with wall contrast enhancement, 10% malignant potential
Cystic neuroendocrine tumor It is a pancreatic NET with a central cystic changes. Solitary lesion, 5-6th decades, frequently with wall contrast enhancement, 10% malignant potential
Cystic neuroendocrine tumor management: asymptomatic and <2 cm you may follow the patient https://doi.org/10.1159/000443171
It seems that these cystic NET are less aggressive than solid NET
ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic...

https://doi.org/10.1159/000443171
Finally,solid pseudopapillary neoplasm
They have malignant potential(15%), >risk if >5 cm
Young women=90% (2-3rd decades),body/tail.Solid and cystic solitary masses, calcifications,often with intracystic bleeding.They can spread to the peritoneum or distant organs like the liver
Finally,solid pseudopapillary neoplasmThey have malignant potential(15%), >risk if >5 cmYoung women=90% (2-3rd decades),body/tail.Solid and cystic solitary masses, calcifications,often with intracystic bleeding.They can spread to the peritoneum or distant organs like the liver
Finally,solid pseudopapillary neoplasmThey have malignant potential(15%), >risk if >5 cmYoung women=90% (2-3rd decades),body/tail.Solid and cystic solitary masses, calcifications,often with intracystic bleeding.They can spread to the peritoneum or distant organs like the liver
This twitter thread was based on:
https://doi.org/10.1038/s41575-019-0195-x
https://doi.org/10.1136/gutjnl-2018-316027
https://doi.org/10.1016/j.suc.2017.09.013
And Pancreatic cystic neoplasms, several articles from @UpToDate Editors: JR Saltzman S Grover Authors: Asif Khalid, MDKevin McGrath, MD http://www.uptodate.com 
Smarter Decisions. Better Care.

UpToDate, the evidence-based clinical decision support resource from Wolters Kluwer, is trusted at the point of care by clinicians worldwide.

https://doi.org/10.1038/s41575-019-0195-x
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