Pancreatic cystic tumors (PCTs)
What is it?
Pancreatic cystic tumors constitute a heterogeneous group of diseases with different biological behavior. They fall into two main categories: serous cystic tumors and mucinous cystic tumors. Serous cystic tumors are almost always benign but can undergo expansive growth, while mucinous tumors may undergo malignant transformation. Fortunately, in most cases even mucinous tumors are diagnosed when they are still benign, and then, depending on the individual case and cyst characteristics, a decision can be made about surgical intervention or a surveillance program with periodic MRI and/or echoendoscopy.
Mucinous tumors are divided into mucinous cystadenomas and intraductal papillary mucinous tumors (IPMN). When malignant transformation has already occurred, they speak of cystadenocarcinomas or intraductal papillary-mucinous carcinomas. IPMNs are the most common cystic neoplasms, and their occurrence is associated with increasing age. Over the age of 80, IPMN occurs in approximately 20% of the population. IPMN can be divided into three types: peripheral (branch duct), mixed (mixed) and central (main duct). Central or mixed IPMNs have a risk of malignant transformation of about 60% at 5 years, whereas peripheral IPMNs have a much lower risk of 2-5% at 5 years.
Therefore, while central or mixed ducts are often an indication for surgical intervention, peripheral or brunch ducts are considered only in the presence of other risk factors. Typically, peripheral lesions are monitored over time with radiological and hematochemical studies according to international guidelines. There are other rarer cystic lesions with a more solid component, such as solid pseudopapillary tumor and cystic neuroendocrine tumor.
Which are the symptoms?
Often they do not cause any discomfort and are discovered by chance, during ultrasound or CT scans done for other reasons. In other cases, especially if they are large, they may show the following symptoms:
- pain, usually not very intense, referred to as heaviness in the upper abdomen;
- nausea or vomiting if the cyst compresses the stomach or duodenum;
- jaundice (i.e., yellow skin and eyes) if the cyst compresses the choledochus;
- episodes of acute pancreatitis, i.e. acute inflammation of the pancreas, manifested by sudden, very intense pain. In these cases, pancreatitis is caused by very thick mucus produced by some cystic tumors (IPMN) that “clogs” the pancreatic ducts. Another symptom that is more difficult to detect may be new diabetes or worsening of existing diabetes despite the same treatment.
How is it diagnosed?
A cystic tumor should not be confused with a pseudocyst, as the treatment of these two diseases is very different. Detection of pancreatic or peripancreatic fluid accumulation in a patient with chronic pancreatitis or acute pancreatitis is almost certainly a manifestation of a pseudocyst. However, when fluid accumulation is found in a patient with no previous history of pancreatic disease, it may be a manifestation of a cystic pancreatic tumor. Another important aspect is the epidemiology of these lesions. For example, mucinous cystadenomas are more common in women and in the tail of the pancreas. Another important aspect is the epidemiology of these lesions. For example, mucinous cystadenomas are more prevalent in females and in the tail of the pancreas.
Blood tests usually do not show significant changes; usually, tumor markers should be evaluated, which can often be normal, as well as glycemia and glycated hemoglobin to assess endocrine function of the pancreas.
Instrumental examinations that can provide useful information when a cystic tumor is suspected include CT scan, but MRI (magnetic resonance imaging) are even more useful, particularly with specific cholangio-Virsungo-RMN sequences and, above all, ecoendoscopy, which allows accurately assess the walls of the cyst, highlight any internal vegetation and take cells or fluid from the cyst, on the basis of which specific tests can be carried out (intracystic markers, amylase and intracystic glucose.
Suggested exams
How is it treated?
A duodenocephalopancreasectomy, distal pancreasectomy and less commonly an intermediate pancreasectomy or complete pancreasectomy may be indicated if surgical intervention is necessary. In some cases of benign cysts, preservation of the spleen during distal pancreatectomy may be considered. In cases of lesions suspected of being malignant or pre-malignant, such as mucinous lesions and, in particular, IPMNs, removal of the spleen during distal pancreatectomy is usually recommended. Often some of these cystic neoplasms can be safely kept under observation, but the decision to do so should be made by a specialist in accordance with current guidelines.
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Where do we treat it?
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