Cystic tumours of the pancreas and PanIN

Cystic tumours of the pancreas

Classically rare :
- 5% of pancreatic tumours
- 5 to 10% of pancreatic cystic lesions (pseudocysts = 90%)

Most of pancreas cystic tumor accidentaly detected at radiologic

examination.
 Classification of pancreatic cystic tumours
Epithelial cystic tumours
et al 2004

Benign
Intraducal papillary mucinous adenoma Non tumorous epithelial cysts
Mucinous cystadenoma Congenital cyst
Serous cystadenoma (micro or macro-cystic)
Lymphoepithelial cyst
Benign cystic neuroendocrine tumour
Acinar cell cystadenoma Non neoplastic mucinous cyst
Dermoid cyst Obstructive cyst
Cystic hamartoma
Endométrial cyst
Borderline
Borderline IPMT Non epithelial cystic tumours
Borderline mucinous cystic tumour Benign (lymphangiomas…)
Solid pseudopapillary tumour Malignant (sarcomas…)
Malignant
Non tumorous non epithelial cysts
IPM carcinoma
Mucinous cystadenocarcinoma Pseudocysts
Serous cystadenocarcinoma Parasitic cysts
Cystic pancreatoblastoma
Cystic metastasis
Malignant cystic neuroendocrine tumour
 Relative frequency of cystic neoplasm of the pancreas

Warshaw et al AFC 1997 Kosmahl et al

130 cases 527 cases 418 cases*

Serous cystadenomas 49% 32% 10%

Mucinous cystic neoplasma 31% 44% 8%

IPMT 11,5% 11% 18%

Solid pseudopapillary neoplasma 3% 4% 21%

Cystic endocrine tumor 1,5% 2% 4%

*includes pseudocysts
 Clinical features
MEDIAN AGE FEMALE (%) SYMPTOMS HEAD (%)

Serous 65 yrs 80 pain + 40

cystadenoma mass +/-
fortuitous +++

MCN 60 yrs 90 pain +++ 20

mass ++
fortuitous +

IPMN 55 ans 40 acute 60

pancreatitis
+++
fortuite ++
Solid PP tumour 25 yrs 98 mass +
fortuitous +
 Serous cystadenoma
0 CT
0 Classic type depicted as a solitary mass that has a central
calcification and radial arrangement of dense connective tissue that
limits the cysts. In some tumors the cysts are very small and tissue
binding so dense that may appear as a solid lesion. The cysts have a
density similar to the density of water, and around the dense
connective tissue.
0 Oligocystic type can be suspected when there is a picture
nonenhancing unilocular cyst mass on the head of the pancreas with
lobulated contours.
0 MRI
0 The lesions will appear as a collection of small cysts in the pancreas,
and theres no communication between the cyst and the pancreatic
duct. At T1, the liquid component was darker than the fibrous
matrix. At T2, the liquid component will look brighter because T2
relaxation time is longer.
 Serous cystadenoma

• Often fortuitously discovered

• Pancreatic head in women > 60 yrs
• Typical microcystic appearence on imaging

• Benign : no surgery
 Precancerous lesions of the pancreas
• Cancer of the pancreas = ductal adenocarcinoma
• Poor prognosis, poorly recognised fisk factors, no
mass screening
• Only 3 recognised precancerous lesions:
• Mucinous cystic neoplasms (MCN)
• Intraductal papillary mucinous neoplasms (IPMN)
• Pancreatic intraepithelial neoplasia (PanIN)
 MCN
0 CT
0 The lesions appear as large cysts with thin septa, best viewed using
contrast. When calcification occurs, the lesions will become lamellated
(the opposite of a starburst pattern that appears to exist SCA), theres
also has peripheral calcification (different from that in the central
SCA). Lesions with higher degrees of epithelial atypia would presence
nodules in the wall lesions, calcification of the peripheral and internal
architecture which is more irregular. Malignant lesions tend to be
larger than the benign lesions.

0 MRI
0 Lesions may appear as unilocular or cystic lesions with minimal septa.
The walls are thick and will Enhance on MRI examination delayed
contrast. Lesions will appear bright on T2. At T1, required intravenous
gadolinium to show septation. The mucin can produce a lower intense
on the center of the lesion, so that the examiner should be able to
distinguish it from radiating septa at SCA. Their internal soft tissues
that Enhance can indicate carcinoma.
 MCNs

• Female, body and tail

• Independant from the ductal system
• Uni or multicystic (cysts >2cm)
• Various histogenetic hypotheses

• Premalignant : must be removed

PanIN and IPMN

Hruban, 2004
 Comparison PanIN - IPMN

PanIN IPMN
Clinical Dg No Yes
Visible on macroscopy. No Yes
Mucin visible on macro No Yes
True papillae No Yes
MUC2 + No Yes
Loss SMAD4 30% PanIN3 Rare
Assoc. Mucinous AK No Yes

Hruban et al, Am J Surg Pathol 2004

 IPMN
0 Pathological markers of these lesions are diffuse or segmental
dilatation of main pancreatic duct or its branches, intraductal
growth of epithelial lining cells that produce mucin, prostution
and dilatation of the papilla major and minor with the excretion of
mucus. These dilated ducts can be wrong sometimes observed as
a cyst.
0 There are two forms of the morphology of IPMN that can be
distinguishable. One involving the main pancreatic duct and the
other one that only involve duct branch.
0 IPMN that involve the branch ducts has appearance: small cysts
lined with lobulated and septate. Radiological diagnosis of branch
duct type IPMN is to identify the relationship between the main
pancreatic duct cyst, where it is best viewed using MRCP. If MRCP
failed to get the relationship between the lesion with the main
pancreatic duct, it can be considered using ERCP.
 SOLID AND PSEUDOPAPILLARY
NEOPLASM
0 The lesions appear round, encapsulated by connective
tissue and necrotic focus of varying amounts.
0 CT and MRI can show a heterogeneous picture because the
hemorrhage and necrosis. Regional bleeding degeneration
appear as fluid-debris level or hyperintense on T1

0 MRI
0 Blood will show hyperintense signal in T1. No septation
appearance, central and perifer calcification occur in 29%
patients.