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Pancreatic cystic lesion

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Pancreatic cysts are abnormal fluid-filled growths on or in the pancreas. There are several types of cysts, many of which are benign (non-cancerous) and some of which are associated with pancreatitis, or inflammation of the pancreas. Cystic neoplasms of the pancreas include serous cystadenomas, mucinous cystadenomas, intraductal papillary mucinous neoplasm (IPMN), and cystically degenerated pancreatic neuroendocrine tumors.

Pancreatic cysts are mostly incidentally identified when abdominal imaging is performed for unrelated indications. The prevalence of incidental pancreatic cysts is 2.6%, with an increased prevalence in the elderly of approximately 8% Little information is presently available on the natural history of pancreatic cysts, which can be classified as benign, pre-malignant, or malignant. However, making an accurate discrimination among these categories using the current diagnostic techniques remains challenging

Serous Cystadenoma

Serous Cystadenoma (SCA) most commonly detected in women in 6-7th decade of age. It is a benign and slow growing lesion. It can be located throughout the pancreas. The size can be variable. SCA usually consist of multiple small cysts which would assume a ‘honeycomb’ appearance on imaging. SCA is a benign lesion that has a very small potential to develop into a malignant condition. Surgery will only be considered when the cyst become symptomatic or large, otherwise observation should be considered.


Mucinous Cystadenoma

Mucinous cystadenoma (MCN) usually occurs middle aged women. MCN is often detected incidentally as a solitary lesion or unilocular cyst. It is usually located in body/tail of pancreas. It is a pre-malignant lesion which has the potential to transform into cancerous condition. Therefore, surgery is often recommended especially to those who are younger and healthy patient.

Intraductal Papillary Mucinous Neoplasm of Pancreas (IPMN)

Intraductal Papillary Mucinous Neoplasm of Pancreas (IPMN) is a slow growing lesion which has malignant potential. It is broadly categorized into two groups:

Main duct IPMN (MD-IPMN)

MD-IPMN may be asymptomatic, but sometime it can present with symptom of acute pancreatitis. On radiological imaging, dilated main pancreatic duct is often seen. Sometime, a patulous ampulla of Vater, with ‘fishmouth’ appearance extruding mucinous material can be seen on endoscopic evaluation. MD-IPMN is a premalignant condition, the frequency of malignancy had been reported up to 60%. For this reason, surgical resection, especially in healthy individuals, is often recommended to remove the affected portion of the pancreas.

Brach duct IPMN (BD-IPMN)

BD-IPMN have malignant potential. Many are asymptomatic and are identified on imaging studies done for another indication. However, these cysts can cause pancreatitis or jaundice. These cysts may be found in various locations throughout the pancreas and have equal frequency in both genders. Distinguishing BD-IPMN from other pancreatic cystic lesions is challenging.

The lifetime risk of one of these cysts becoming malignant is reported to be lower than MD-IPMN. There is no medication to treat these cysts. Patients and their doctors are forced to choose between surveillance and surgical removal. Factors that contribute to this decision include the patient’s age, presence or absence of symptoms, the size of the cyst, and whether or not there is a solid component or mural nodule. While surgical removal of these cysts will prevent the patient from developing pancreatic cancer from that cyst, pancreatic surgery is not without risk. The risk of the surgery must be carefully weighed against the risk of malignancy in making a determination about surgical removal versus surveillance.

Patients with the branch duct variant of IPMN generally can be safely observed if:

  1. The cyst is asymptomatic
  2. The cyst is less than 3 cm
  3. The cyst has no solid component or mural nodule

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