Diagnosis and treatment of pancreatic pseudocysts and cystic tumors based on own material and quoted literature

Abstract

Pseudocysts constitute the most basic cystic lesions of the pancreas. Symptomatic cysts may be treated by means of both minimally invasive methods and surgery. Currently, it is believed that approximately 5% of cystic lesions in the pancreas may in fact, be neoplastic cystic tumors. Their presence is manifested by generally irregular multilocular structures, solid nodules inside the cyst or in the pancreatic duct, frequently vascularized, as well as fragmentary thickening of the cystic wall or septation.

Aim: The aim of this paper was to present current management, both diagnostic and therapeutic, in patients with pancreatic pseudocysts and cystic tumors. The article has been written based on the material collected and prepared in the author's Department as well as on the basis of current reports found in the quoted literature.

Material and methods results: In 2000-2012, the Second Department of General, Gastrointestinal and Oncological Surgery of the Alimentary Tract treated 179 patients with cystic lesions in the region of the pancreas. This group comprised 12 cases of cystic tumors and 167 pseudocysts. Twenty-three patients (13.8%) were monitored only and 144 received procedural treatment. Out of the latter group, 75 patients underwent drainage procedures and 48 were qualified to endoscopic cystogastrostomy or cystoduodenostomy. The endoscopic procedure was unsuccessful in 11 cases (23%). In a group of patients with a pancreatic cystic tumor (12 patients), 6 of them (50%) underwent therapeutic resection of the tumor with adequate fragment of the gland.

Conclusions: Endoscopic drainage is an effective and safe method of minimally invasive treatment of pancreatic cysts. The patients who do not qualify to endoscopic procedures require surgical treatment. The differentiation of a neoplasm from a typical cyst is of fundamental significance for the selection of the treatment method.

Keywords: imaging diagnosis; pancreatic cystic tumors; pancreatic cysts; principles of qualification to treatment; treatment method.

Fig. 1

Pancreatic retention pseudocyst in association with chronic pancreatitis. Parenchymal calcifications (arrow), ductal dilatation (Wirsung) and atrophy of the parenchyma

Fig. 2

Post-necrotic pseudocyst that develops after an episode of acute pancreatitis. Such a pseudocyst is well-defined by a fibrous capsule, usually contains enzymatic fluid and necrotic debris (arrow)

Fig. 3 A

EUS. EUS-guided pancreatic pseudocyst drainage. Puncturing the pseudocyst and inserting a guidewire

Fig. 3 B

EUS-guided cystogastrostomy. Insertion of the stent to the lumen of the pseudocyst

Fig. 3 C

Effective endoscopic pseudocyst drainage. The pancreatic juice flows through cystogastrostomy (prosthesis is inserted to the lumen of the pseudocyst)

Fig. 4 A

Serous cystadenoma (microcystic type). A typical serous tumor is composed of multiple small cysts and has a “honeycomb” appearance. The cystic mass is situated in the pancreatic tail, about 5 cm in diameter

Fig. 4 B

IOUS. Well-defined microcystic tumor, poorly vascularized, adhering to the splenic vessels (arrow) (color Doppler)

Fig. 4 C

Doppler US. Serous cystadenoma in the head of the pancreas, poorly vascularized, 5.6 cm in diameter. Similar “honeycomb” structure with oligocystic components and central scar (arrow)

Fig. 4 D

Contrast-enhanced CT shows a classic serous cystadenoma in the head of the pancreas (4.1 × 2.9 cm). The lesion has the appearance of a solid mass with numerous small cysts and septations – “honeycomb” structure. The calcified central scar (arrow)

Fig. 5 A

Computed tomography. Serous cystadenoma situated in the pancreatic body. A symptomatic lesion, 5.5 cm in the diameter, qualified to surgical resection

Fig. 5 B

IOUS. Micro- and oligocystic serous cystadenoma, “honeycomb” appearance. During surgical resection

Fig. 5 C

Serous cystadenoma, after surgical distal resection of the pancreas. Postoperative specimen

Fig. 6

Contrast-enhanced CT – a small hypodense cystic tumor in the pancreatic tail (2.5 × 2 cm). Poorly vascularized, multiple small cysts with polycyclic border of the tumor

Fig. 7

IOUS. Uni- or multilocular mucinous cystadenoma with septations composed mainly of large cystic lesions. Normal pancreatic tissue (T). The cystic lesion is situated in the head of the pancreas with low-grade dysplasia (arrows)

Fig. 8 A

US – power Doppler. Mucinous cystadenocarcinoma. Irregular cystic wall thickening, peripheral calcifications and intramural solid nodules – signs of malignancy. Tumor in the body/tail of the pancreas, 6.5 cm in diameter. Qualified to surgical resection

Fig. 8 B

IOUS. Mucinous cystadenocarcinoma during surgical resection, estimation of tissue infiltration. Cystic neoplasm with reduced fluid capacity, mainly growth of solid tissue

Fig. 9 A

Solid pseudopapillary neoplasm (SPN). A large symptomatic lesion, well-circumscribed, surrounded by a thick capsule. The tumor localized in the tail of the pancreas, approximately 10 cm in diameter. The content of the lesion is solid with signs of necrosis or hemorrhage which are responsible for the cystic capacity. The tumor with malignant potential

Fig. 9 B

Malignant transformation of SPN. Small metastases in the liver (arrow)

Fig. 9 C

SPN. Contrast-enhanced CT scans show a mixed solid and cystic mass in the pancreatic head (10 × 7.5 cm). Thick, well-circumscribed capsule, hyperdense areas due to hemorrhage, and areas of necrosis