Cystic Lesions Of The Pancreas Research Articles

Optimal Follow-up of Incidental Pancreatic Cystic Lesions without Worrisome Features: Clinical Outcome after Long-term Follow-up.

: The optimal duration and interval of follow-up for cystic lesions of the pancreas (CLPs) is not well established. This study was performed to investigate the optimal duration and interval of follow-up for CLPs in clinical practice. : Patients with CLPs without worrisome features or high-risk stigmata underwent follow-up with computed tomography at 6, 12, 18, and 24 months and then every 12 months thereafter. A retrospective analysis of prospectively collected data was performed. : A total of 227 patients with CLPs detected from 2000 to 2008 (mean initial diameter, 1.3±0.6 cm) underwent follow-up for a median of 120 months. Twenty-two patients (9.7%) underwent surgery after a median of 47.5 months. Malignancies developed in four patients (1.8%), one within 5 years and three within 10 years. One hundred and fourteen patients (50.2%) were followed up for more than 10 years. No malignancy developed after 10 years of follow-up. During surveillance, 37 patients (16.3%) experienced progression to surgical indication. In patients with CLPs less than 2 cm in diameter, development of surgical indications did not occur within 24 months of follow-up. : CLPs should be continuously monitored after 5 years because of the persistent potential for malignant transformation of CLPs. An interval of 24 months for initial follow-up might be enough for CLPs with initial size of less than 2 cm in clinical practice.

Commentary on: Multi-institutional Validation Study of Cyst Fluid Protein Biomarkers in Patients With Cystic Lesions of the Pancreas.

Commentary on: Multi-institutional Validation Study of Cyst Fluid Protein Biomarkers in Patients With Cystic Lesions of the Pancreas.

Contribution of Endoscopic Ultrasound (EUS) in Biliopancreatic Pathology: Experience of the Hepato Gastroenterology Moroccan Department

Introduction: Endoscopic ultrasound (EUS) is a method of exploration in gastroenterology, it combines ultrasound and endoscopy for the examination of the digestive tract and nearby structures. It is an ultrasound technique that allows the use of high-definition ultrasound transducers. Materials and methods: It is a descriptive retrospective study covering a period of 34 months, from 01/2019 to 10/2021. It concerned 100 patients who had endoscopic ultrasound for biliopancreatic pathology, in the and the university hospital Sheikh Khalifa. We noted the demographic, clinical and morphological data, such as transcutaneous ultrasound, abdominal CT scan and MRI as well as the EUS. The results of the EUS were compared with the imaging and histology data when performed. We were therefore able to evaluate the reliability of each examination and thus its strong and weak points. Results: The average age of our patients was 58 years, with a sex ratio: 1.05. The symptomatology was dominated by abdominal pain and jaundice, the biology by cytolysis and biological cholestasis syndrome. We noted a predominance of tumor pathology with 42% followed by inflammatory pathology: acute pancreatitis as part of the etiological assessment. The reliability of EUS in the diagnosis of pancreatic cancer is 88% with a reliability of abdominal CT of 68%. Our study also allowed us to evaluate with precision the reliability of detection of lymph node and vascular invasion of biliopancreatic cancers, which was 88%. We also noted other pathologies for which EUS was a good diagnostic tool, main bile duct stones but also cystic lesions of the pancreas. Conclusion: In view of the comparative study of these results with the other types of explorations, of which the EUS, proved to be more effective in the exploration of the pancreatic region especially in for the assessment of tumor extension and diagnosis of choledocholithiasis and characterization of cystic lesions. The EUS has a therapeutic interest ....

Cystic Lesions of the Pancreas: Is Apparent Diffusion Coefficient Value Useful at 3 T Magnetic Resonance Imaging?

The objective of this study is to determine the role of apparent diffusion coefficient (ADC) value at 3T magnetic resonance imaging (MRI) in the characterization of pancreatic cystic lesions. We retrospectively selected a total number of 223 patients with a conclusive diagnosis of pancreatic cystic lesion, previously undergoing MR examination on a 3 T system. The MRI protocol first included axial T1/T2-weighted sequences and magnetic resonance cholangiopancreatography. Diffusion-weighted MRI was performed using a spin-echo echo-planar sequence with multiple b values (0, 150, 500, 1000, and 1500 s/mm2) in all diffusion directions, obtaining an ADC map. Contrast-enhanced T1-weighted sequences were performed during the initial work-up of a pancreatic cystic lesion and when signs of malignancy were suspected during the MRI follow-up. The ADC value of each pancreatic lesion was measured using a monoexponential curve fitting with all the multiple b. The final diagnosis of our study group included the following: serous cystadenomas (n = 42), mucinous cystadenomas (n = 14), intraductal papillary mucinous neoplasms (IPMNs) (n = 121), IPMNs with signs of malignancy at histopathologic examination (n = 24), pseudocysts (n = 9), other cystic lesions (n = 13). A statistically significant difference was observed between the ADC values of malignant IPMNs and those of each other group of pancreatic lesions (P < 0.001). The ADC value of benign IPMN was significantly higher than that of serous cystadenomas (P = 0.024). A statistically significant difference was observed between the ADCs of all mucinous cystic tumors (benign IPMNs together to mucinous cystadenomas) and the ADCs of serous cystadenomas (P = 0.014). Fitted ADC value obtained at 3T MRI may be helpful in the characterization of pancreatic cystic lesions with particular regards of differential diagnosis between mucinous and serous cystic tumors and between malignant and benign IPMNs.

Pancreatic incidentalomas: Investigation and management.

The incidence of pancreatic incidentalomas (PIs) detected in otherwise asymptomatic patients is growing with the increasing quality and use of advanced imaging techniques. PI can present as isolated main pancreatic duct dilation or as a solid or cystic lesion. Although historically thought to be relatively rare, PIs are rather common, particularly cystic lesions of the pancreas, which can be detected in up to 49% of the general population. With the poor prognosis of pancreatic cancer, PIs are an opportunity for prevention and early diagnosis, but when managed poorly, they can also lead to overtreatment and unnecessary morbidity. The management of PI should begin with a dedicated pancreas protocol computed tomography (CT) scan or magnetic resonance imaging (MRI) to accurately characterize duct size, lesion characteristics and establish an accurate baseline for subsequent follow up. Diagnosis and subsequent management depends on the extent of main duct dilation and solid versus cystic appearance. Solid lesions are highly concerning for malignancy. Cystic lesions can be further categorized as intraductal papillary mucinous neoplasms of the pancreas (IPMNs) or mucinous cystic neoplasms (MCNs), both of which harbour malignant potential, or as serous cystic neoplasms (SCNs) that are benign. In this paper, we summarize the major challenges related to PI and present pragmatic suggestions for management.

S1559 A Huge Surprise: Osteoclastic Giant Cell Tumor of the Pancreas

Introduction: Cystic lesions of the pancreas are often found incidentally on routine imaging. We describe an incidentally discovered pancreatic abnormality which was later confirmed to be a rare malignancy. Case Description/Methods: A 71-year old male with Warthin’s tumor and non-insulin dependent diabetes underwent computerized tomography (CT) of the soft tissues of the neck and the sinuses, incidentally demonstrating ground glass lung opacities. CT of the thorax then revealed sub-centimeter pulmonary nodules and an incidental 2.5 cm cystic mass at the pancreatic head, with biliary and pancreatic duct dilation. A pancreatic protocol CT confirmed a necrotic mass in the pancreatic head measuring approximately 3 cm, with pancreatic duct dilation up to 5 mm in the pancreatic neck. Scout EGD was unremarkable. Echoendoscopy was performed demonstrating a multi-cystic head of pancreas lesion measuring 2.8 cm x 2.8 cm, which was sampled with fine needle biopsy. Histology of the sample confirmed osteoclastic giant cell tumor, with immunohistochemistry showing cells positive for CD68, CD4, CD45, and vimentin, and negative for cytokeratin and pan-keratin. The patient underwent uncomplicated pancreaticoduodenectomy (Whipple’s procedure) with negative margins. The gross specimen (3.2 x 3.1 x 2.9 cm) confirmed undifferentiated carcinoma with osteoclast like giant cells. Discussion: Pancreatic adenocarcinoma is the most common type of pancreatic neoplasm, typically involving the pancreatic head. Pancreatic giant cell tumors (PGCT), officially termed “undifferentiated carcinoma with osteoclast-like giant cells) by the WHO, occur with an incidence of less than 1% of all pancreatic tumors. PGCTs rarely involve the pancreatic head, and typically occur in the body or tail of the pancreas. Typically occurring between the 6th and 7th decade of live, there is no preponderance between sexes. Three types are known: osteoclastic, pleomorphic, and mixed. Osteoclastic PGCT is thought to have the most favorable prognosis. Immunohistochemistry is critical in differentiating between osteoclastic and pleomorphic types, as pleomorphic GCT – typically positive for vimentin – are aggressive and more likely to metastasize. This patient did well with en-bloc surgical resection alone, though radiation therapy is sometimes offered depending on tumor size. In summary, we describe a rare pancreatic malignancy that was incidentally detected, diagnosed by EUS-FNB and successfully managed surgically.Figure 1.: a) CT pancreas demonstrating head of pancreas (HOP) lesion b) HOP mass on echoendoscopy c) gross specimen.

Surgical outcomes are hampered after endoscopic ultrasonography-guided ethanol lavage and/or Taxol injection in cystic lesions of the pancreas.

Backgrounds/AimsEndoscopic ultrasonography-guided ethanol lavage and Taxol injection (EUS-ELTI) for pancreatic cystic lesions have been recently performed in some medical centers. The aim of this study was to optimize patient selection and analyze outcomes of patients who underwent surgeries after EUS-ELTI for pancreatic cystic lesions.MethodsAmong 310 patients who underwent EUS-ELTI between January 2007 and December 2014, 23 underwent surgeries after EUS-ELTI owing to incomplete treatment and/or adverse events. Surgical outcomes of patients who underwent surgeries after EUSELTI were evaluated. Clinical outcomes of patients who underwent surgeries after EUS-ELTI were then retrospectively compared with those of patients who underwent upfront surgery for left-sided pancreatic lesions without an EUS-ELTI procedure.ResultsThe pathology revealed degenerated cysts in 12 patients, mucinous cyst neoplasms in five, neuroendocrine tumors in two, intraductal papillary mucinous neoplasm (IPMN) in one, solid pseudopapillary tumor in one, pancreatic ductal adenocarcinoma arising from an IPMN in one, and hepatoid carcinoma in one. Twelve patients underwent laparoscopic distal pancreatectomy and five patients underwent open distal pancreatectomy. When clinical outcomes were retrospectively compared between patients who underwent laparoscopic distal pancreatectomy after EUS-ELTI and those who did not receive an EUS-ELTI procedure, the spleen-preserving rate was 0% in the EUS-ELTI group and 61.7% (365/592) in the control group (p < 0.001).ConclusionsSurgical outcomes are compromised after EUS-ELTI for cystic tumor of the pancreas. Further studies are needed to investigate the efficacy and safety of the EUS-ELTI procedure.

English

A frequent cause for patient presentation to the emergency department and the most serious gastrointestinal condition resulting in admission is acute pancreatitis. Pancreatitis is an inflammatory process within the pancreas. Although the disease is mostly mild, the mortality rate of severe forms may be up to 30 percent. Two of the following three criteria are required for diagnosis: epigastric abdominal pain, elevated lipase, and pancreatic inflammation on imaging.1 The occurrence of acute pancreatitis is approximately 1 in 1000 to 5000 births and is commonly seen in the last weeks of gestation or in post-partum period. Cholelithiasis, which accounts for more than 65 percent of cases, is the most common cause of acute pancreatitis in pregnancy.2 Pancreatic ascites results from persistent leakage of pancreatic secretions in the peritoneum from pancreatic duct injury. The extent of pancreatic ascites varies, depending on the site and degree of ductal damage and infection.3 The complications of acute or chronic pancreatitis are pancreatic pseudocysts. Initial diagnosis is mostly done by imaging. Endoscopic ultrasound with fine needle aspiration cytology (FNAC) has become the standard test to help differentiate pseudocyst from other cystic lesions of the pancreas. With supportive treatment, most pseudocysts resolve spontaneously. Poor predictors for the potential of pseudocyst resolution or complications are the size of the pseudocyst and the length of time the cyst has been present, but larger cysts in general are more likely to be symptomatic or cause complications.4 We report a case of young female presenting with jaundice and ascites two days post-partum, who was eventually diagnosed as a case of pancreatic ascites with large pancreatic pseudocyst.

Cystic lesions of the pancreas: How accurate is the preoperative diagnosis?

Cystic lesions of the pancreas: How accurate is the preoperative diagnosis?

Simple mucinous cyst: another potential cancer precursor in the pancreas? Case report with molecular characterization and systematic review of the literature

Cystic lesions of the pancreas may range from benign to precursors of pancreatic cancer. Simple mucinous cyst (SMC) is larger than 1 cm, has a gastric-type flat mucinous lining, and minimal atypia without ovarian-type stroma. We report a new case of pancreatic SMC, coupling a systematic review of the English literature mainly focused on their clinic-pathological features. We reviewed 103 cases of SMC in adults (73 women), averaging 57 (range, 26–70) years. The SMCs were located in the body-tail region of the pancreas in 60 (58%) cases, presenting as single cystic lesions in 94% of cases; 43% of patients were asymptomatic. A preoperative fine-needle aspiration of the cyst fluid detected amylase and carcinoembryonic antigen positivity in 71% and 76% of cases, respectively. Patients underwent surgery mostly for suspected malignancy; in 83% of cases, a standard pancreatic resection was performed. Mean SMC size was 4.9 (range, 1.5–12.0) cm. Mucins MUC5AC and MUC6 resulted positive in 77% and 81% of cases performed, respectively, whereas MUC2 was negative in all but one patient. The SMC from our institution was characterized by a KRAS somatic mutation. The diagnosis of SMC should be considered when a solitary pancreatic cyst larger than 1 cm is detected in asymptomatic patients. To establish a correct diagnosis, an extensive histologic/immunohistochemical analysis is essential. The presence of a KRAS mutation highlights that SMC may represent another potential pancreatic cancer precursor.

Cystic lesions of the pancreas: how accurate is the preoperative diagnosis?

Purpose: Many cystic lesions of the pancreas do not require resection. To avoid overtreatment and associated morbidity, it is important to accurately distinguish benign and (pre)malignant cysts in the diagnostic process. This study evaluates the accuracy of the preoperative diagnosis of all resected pancreatic cystic lesions in a regional network consisting of 4 Hepato-Pancreato-Biliary surgery (HPB) referral centers. Method: Data from the prospective Dutch Pancreatic Cancer Audit were analyzed, including all patients with a preoperative or postoperative diagnosis of pancreatic cystic lesion undergoing resection between 2013 and 2019.The preoperative diagnoses were determined in a multidisciplinary HPB consultation meeting in which patient characteristics, standardized preoperative examinations, preoperative imaging data and if available results of endoscopic ultrasound were evaluated. The postoperative pathological diagnosis was considered the gold standard for definitive classification. Results: A total of 219 patients were included. The preoperative diagnosis was IPMN (55.3%), MCN (10.5%), SCN (1.4%), adenocarcinoma (15.6%), NET (2.3%), SPN (1.4%), benign disease (6.4%) and ‘other’ (6.9%). Indications for surgery were suspected (pre)malignant disease, large cyst size and/or presence of related abdominal symptoms.The overall accuracy of the preoperative diagnosis was 42.5% (N=93; table 1). Presumed IPMN was confirmed in 71 (58.7%) patients and MCN in 8 (34,8%) patients.However, the preoperative diagnosis was inaccurate in 29/30 (96.7%) patients with SCN. In retrospect, 65 (29.7%) patients underwent surgery for benign disease, of whom 4 (6.2%) because of presence of insurmountable abdominal symptoms. Conclusion: In over fifty percent of cases the preoperative diagnosis was different from the definitive diagnosis. 27.9% of our cases underwent unnecessary surgery. Further optimization of a correct diagnosis of pancreatic cysts is warranted to avoid unnecessary surgery.

Changing trends in the clinicopathological features, practices and outcomes in the surgical management for cystic lesions of the pancreas and impact of the international guidelines: Single institution experience with 462 cases between 1995-2018

IntroductionThe impact on clinical practice of the international guidelines including the Sendai Guidelines (SG06) and Fukuoka Guidelines (FG12) on the management of cystic lesions of the pancreas (CLP) has not been well-studied. The primary aim was to examine the changing trends and outcomes in the surgical management of CLP in our institution over time and to determine the impact of these guidelines on our institution practice. Methods462 patients with surgically-treated CLP were retrospectively reviewed and classified under the 2 guidelines. The cohort was divided into 3 time periods: 1998–2006, 2007–2012 and 2013 to 2018. ResultsComparison across the 3 time periods demonstrated significantly increasing frequency of older patients, asymptomatic CLP, male gender, smaller tumor size, elevated Ca 19-9, use of magnetic resonance imaging (MRI) and use of endoscopic ultrasound (EUS) prior to surgery. There was also significantly increasing frequency of adherence to the international guidelines as evidenced by the increasing proportion of HRSG06 and HRFG12 CLP with a corresponding lower proportion of LRSG06 and LRFG12 being resected. This resulted in a significantly higher proportion of resected CLP whereby the final pathology confirmed that a surgery was actually indicated. ConclusionsOver time, there was increasing adherence to the international guidelines for the selection of patients for surgical resection as evidenced by the significantly increasing proportion of HRSG06 and HRFG06 CLPs undergoing surgery. This was associated with a significantly higher proportion of patients with a definitive indication for surgery.These suggested that over time, there was a continuous improvement in our selection of appropriate CLP for surgical treatment.

Pancreatic cystic lesions in diabetes mellitus patients.

IntroductionAccording to the literature exocrine pancreatic insufficiency is relatively common among patients with diabetes mellitus (DM). Pseudocysts are the most common cystic lesions and may be formed in the setting of acute or chronic pancreatitis. However, whether DM is involved or not in pancreatic cyst formation is still not well established.AimTo investigate the frequency and risk factors of cystic lesions in diabetic patients.Material and methodsOne hundred and sixty-one patients with DM, with no previous history of pancreatic diseases, were prospectively included in the study. Endosonography followed by fine needle aspiration biopsy was then performed.ResultsFinally, 33 of 161 patients (20.5%) were recognized with cystic lesions of the pancreas. Among them 5 patients were classified as cystic neoplasms, and 28 as pseudocysts. In the group of patients with pseudocysts, cystic lesions were significantly more prevalent in individuals with DM lasting less than 3 years. Prevalence of cystic lesions was significantly higher in metformin users in comparison to other diabetic patients (p < 0.05). Cystic lesions were more frequent in patients above 50 years of age (p < 0.05).ConclusionsThe prevalence of cystic lesions in the diabetic population is higher than in the general population. DM seems to play a major role in the process of cyst development, especially in patients without previous history of pancreatitis. Higher prevalence of cystic lesions in early diabetes seems to be the first stage of pancreatic injury. The exact role of diabetes duration and type of treatment should be established.

Clinical and radiological features that predict malignant transformation in cystic lesions of the pancreas: a retrospective case note review.

Background: Pancreatic cystic lesions (PCL) are being detected with increasing frequency. Current methods of stratifying risk of malignant transformation are imperfect. This study aimed to determine the frequency of pancreatic malignancy in patients with PCL and define clinical and radiological features that predict malignant transformation in patients managed by surgery and/or surveillance. Methods: A retrospective cohort of adults who were evaluated in a tertiary hepatopancreaticobiliary centre between January 2000 - December 2013 with a confirmed PCL and followed up for at least 5 years. All cystic lesions were discussed at a weekly multidisciplinary meeting. Results: Of the 1,090 patients diagnosed with a PCL, 768 patients were included in the study: 141 patients were referred for immediate pancreatic resection, 570 entered surveillance while 57 had a malignant PCL which was unresectable at diagnosis (n=47) or were unfit for surgery (n=10). In those who were resected following presentation, malignancy was present in 38%. During follow-up 2% of those entering a surveillance programme underwent malignant transformation. Clinical and radiological features associated with a high-risk PCL included older age, symptoms, associated solid component or dilated main pancreatic duct. In intraductal papillary mucinous neoplasms, larger size was not a feature of malignant transformation (benign vs. malignant 30mm vs. 23mm; P= 0.012). Conclusion: The sensitivity of standard diagnostic tests leading to immediate surgery for high-risk PCL (malignant or mucinous) was 92% but with a specificity of just 5%. Surveillance of PCL without high-risk features within a multidisciplinary meeting was associated with a low incidence of cancer development, supporting the use of worrisome clinical and radiological features in the initial stratification of PCL.

Cystic Lesions of the Pancreas - Expect the Unexpected: Co-Occurence of a Mixed Duct-Type Pancreaticobiliary IPMN and a Microcystic Serous Cystadenoma - A Case Report

Cystic Lesions of the Pancreas - Expect the Unexpected: Co-Occurence of a Mixed Duct-Type Pancreaticobiliary IPMN and a Microcystic Serous Cystadenoma - A Case Report

Systematic review of the utility of 18-FDG PET in the pre-operative evaluation of IPMNs and cystic lesions of the pancreas

Systematic review of the utility of 18-FDG PET in the pre-operative evaluation of IPMNs and cystic lesions of the pancreas

Cystic Lesions of the Pancreas: Differential Diagnosis and Cytologic-Histologic Correlation.

Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for management, distinguishing between neoplastic and nonneoplastic PCLs is critical. Neoplastic cysts with potential to progress into cancer include mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) and nonmucinous cysts (solid pseudopapillary tumors, serous cystic neoplasms, and neuroendocrine tumors with cystic degeneration). Nonneoplastic cysts with no risk of malignant transformation include pseudocysts, retention cysts, lymphoepithelial cysts, cystic pancreatic lymphangioma, and duplication cyst/ciliated foregut cysts. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology with cyst fluid analysis in the diagnosis of PCLs has evolved during the last decade; however, a definitive diagnosis on cytologic specimens is hampered by the sparse cellularity and can be challenging. EUS-FNA can play an important role to differentiate low-risk from high-risk pancreatic cysts and to distinguish between patients with cysts who need clinical follow-up versus those who require surgery. To provide an integrative approach to diagnose pancreatic cystic lesions using EUS-FNA cytology and cyst fluid analysis, along with clinical, radiologic, histologic, genetic, and molecular characteristics. The review and analysis of the latest literature describing pancreatic cystic lesions. Accurate diagnosis of PCLs requires a multidisciplinary and multimodal team approach, including the integration of clinical findings, imaging, cytology, cyst fluid analysis, and molecular testing.

A prospective trial of CONfocal endomicroscopy in CYSTic lesions of the pancreas: CONCYST-01.

Background and study aims Pancreatic cystic lesions (PCL) are common. While some harbor malignant potential, accurate preoperative diagnosis remains challenging. Needle-based confocal laser endomicroscopy (nCLE) via a 19G FNA needle enables real-time imaging of the cyst wall. This study evaluated the safety and utility of nCLE in patients with an indeterminate PCL undergoing EUS-FNA. Patients and methods The CONCYST study prospectively recruited patients with indeterminate PCL attending three hepatopancreaticobiliary (HPB) referral centers in the UK, with indeterminate PCL, who required EUS-FNA between July 2014 and October 2016. Following the procedure, all patients were followed up in telephone clinic for at least 12 months. Ethical approval for the study was granted by the National Research Ethics Service (14/LO/0040). Results Sixty-seven patient were recruited, 11 excluded and 56 included in the final analysis: 35 male, 21 female; median age 68 (range 28 – 80). Recognizable confocal images were obtained in 48 of 56 cases. Median nCLE scanning time was 5 minutes and did not exceed 10 minutes in any case. EUS-nCLE findings correlated with final diagnosis (based on imaging, cytology and multidisciplinary team review) in 43/56 (77 %) of cases, compared with 37/56 (66 %) for cytology alone ( P = 0.12). One patient experienced mild pruritus following the procedure and another developed an infected pseudocyst, which resolved with antibiotics. Conclusions EUS-nCLE under conscious sedation in the day case setting is safe and provides additional information to standard EUS-FNA for diagnosing indeterminate PCL.

Mucinous nonneoplastic cyst of the pancreas penetrates the colon causing infection: a case report

BackgroundMucinous nonneoplastic cyst of the pancreas is a rare disease defined as a cystic lesion lined with mucinous epithelium, supported by hypocellular stroma and not communicating with the pancreatic ducts. Mucinous nonneoplastic cyst of the pancreas has no malignant potential and does not require surgical resection or surveillance. However, its preoperative differentiation from other cystic lesions of the pancreas is difficult because of several overlapping clinical, radiological, and biochemical features. We report a rare case of large mucinous nonneoplastic cyst of the pancreas in which surgery was required due to infection and the possibility of malignancy.Case presentationA 75-year-old Japanese man was found to have a pancreatic cyst in 2006 while undergoing postoperative evaluation for colon cancer. In 2015, the cyst ruptured, and it was treated conservatively. In 2017, he fell down on a road with a fever of 40 °C and was transported emergently to a nearby hospital. Enhanced computed tomography revealed a cystic lesion in the body of the pancreas measuring 119 mm × 100 mm and an adjacent left renal cyst measuring 63 mm in diameter. The wall of the pancreatic cyst was thickened. Magnetic resonance imaging demonstrated a liquid surface in the pancreatic cyst. Pancreatic cyst infection was diagnosed as the source of infection. However, identification of the organism was difficult. Furthermore, due to the increase in the size and wall thickness of the cyst, it was unclear whether the cystic mass was neoplastic with malignant potential. For these reasons, the patient underwent distal pancreatectomy and splenectomy with deroofing of the left renal cyst. Intraoperatively, the pancreatic cyst adhered to the descending colon, and partial resection of the colon was added. Pathologic analysis of the resected cyst demonstrated a simple cyst lined by mucinous epithelium. There was no underlying stromal condensation or epithelial dysplasia, and communication with the native pancreatic ducts was not observed. Based on the operative and histological findings, a final diagnosis of mucinous nonneoplastic cyst of the pancreas with colonic communication was made. The colonic fistula was presumed to be the source of infection.ConclusionMucinous nonneoplastic cyst of the pancreas is generally benign and requires little follow-up, but large cysts may penetrate other organs and cause severe complications.

Clinical and radiological features that predict malignant transformation in cystic lesions of the pancreas: a retrospective case note review

Background: Pancreatic cystic lesions (PCL) are being detected with increasing frequency. Current methods of stratifying risk of malignant transformation are imperfect. This study aimed to determine the frequency of pancreatic malignancy in patients with PCL and define clinical and radiological features that predict malignant transformation in patients managed by surgery and/or surveillance. Methods: A retrospective cohort of adults who were evaluated in a tertiary hepatopancreaticobiliary centre between January 2000 - December 2013 with a confirmed PCL and followed up for at least 5 years. All cystic lesions were discussed at a weekly multidisciplinary meeting. Results: Of the 1,090 patients diagnosed with a PCL, 768 patients were included in the study: 141 patients were referred for immediate pancreatic resection, 570 entered surveillance while 57 had a malignant PCL which was unresectable at diagnosis (n=47) or were unfit for surgery (n=10). In those who were resected following presentation, malignancy was present in 38%. During follow-up 2% of those entering a surveillance programme underwent malignant transformation. Clinical and radiological features associated with a high-risk PCL included older age, symptoms, associated solid component or dilated main pancreatic duct. In intraductal papillary mucinous neoplasms, larger size was not a feature of malignant transformation (benign vs. malignant 30mm vs. 23mm; P= 0.012). Conclusion: The sensitivity of standard diagnostic tests leading to immediate surgery for high-risk PCL (malignant or mucinous) was 92% but with a specificity of just 5%. Surveillance of PCL without high-risk features within a multidisciplinary meeting was associated with a low incidence of cancer development, supporting the use of worrisome clinical and radiological features in the initial stratification of PCL.