Wednesday, December 23, 2015

Management of Pancreatic Cystic Lesions

Ryan Schwope
Thick slab MRCP image showing massive dilatation of the main pancreatic duct
Incidental cystic pancreatic lesions found on 13% of MRI abdomens
  • Wide variety of pathology both benign and malignant
  • Imaging findings and demographics are the key to diagnosis

Cystic Pancreatic Neoplasms (Four major categories)

  1. Serous cystadenoma: Benign (very low malignant potential)
  2. Mucinous cystic neoplasm (MCN): Premalignant or malignant
  3. Intraductal papillary mucinous neoplasm (IPMN): Malignant potential (Main Duct >> Branch Duct)
  4. Unusual cystic neoplasms:
    • Solid pseudopapillary neoplasm (SPN): Low grade malignancy
    • Cystic forms of more common neoplasms (neuroendocrine)

Nonneoplastic Pancreatic Cysts

  • Pseudocyst
  • Retention cyst
  • Lymphoepithelial cyst
  • Localized ductectasia

Major Imaging Features Guiding Management

  • Number and size of cystic components: Risk of malignancy increases when size ≥ 3 cm
  • Septations and solid components: Mural nodule has a 87% Sp and 56% Sn for malignancy
  • Main pancreatic duct (MPD) dilatation and communication with the cystic lesion: MPD > 10 mm has a 77% Sp and 67-92% Sn for malignancy

Sendai Criteria

High Risk Stigmata
  • Jaundice
  • MPD ≥ 10 mm
  • Enhancing solid component
Worrisome Features
  • Size ≥ 3 cm
  • MPD 5-9 mm
  • Non-enhancing mural nodules
  • Thick enhancing cystic wall
  • Lymphadenopathy
  • Abrupt Duct Termination


  • Any worrisome features present = Endoscopic Ultrasound (EUS) and Cyst aspiration with fluid analysis
  • Any high risk stigmata present or suspicious cytology on EUS = Surgical resection
  • MCN or SPN = Surgical resection
  • Serous cystadenoma
    • 2-3 cm: F/U every 2 years
    • ≥ 4 cm: consider resection
  • IPMN:
    • Main duct and combined type: Surgical resection (but depends on location, pt. age/clinical status)
    • Branch duct type = follow if < 3 cm and contains no solid components
      • If < 2cm F/U q1yr; if growth FU q6mo
      • If 2-3 cm F/U q6mo x 2 years, then q1yr
      • Consider EUS (if mucinous then resect)
      • If growth ≥ 3 cm, resect

What the Clinician/Surgeon wants to know

  1. Number of cystic lesions
  2. Largest cystic lesion
    • Unilocular
    • Multilocular: Microcystic (<2cm) or Macrocystic (> 2cm)
  3. Lesion size
  4. Lesion location: Head/Body/Tail
  5. Septations: None/Thin/Thick (> 2mm)
  6. Solid components: Present/Absent
  7. Calcifications: None/Coarse/Rim/Central
  8. Communication with MPD: Present/Absent
  9. Main pancreatic duct diameter: > 5 mm/Not dilated


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