What You Need to Know About Pancreatic Cysts

What You Need to Know About Pancreatic Cysts

July 26, 2019 25 By William Morgan


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My name is Anne Marie Lennon.
I am an assistant professor of medicine
here at Johns
Hopkins, and I am the director of the
Pancreatic Cyst Clinic.
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The pancreas is at the top of your tummy,
and in fact it sits on
top of your spine, so it’s at the back,
and it’s divided into three portions.
The top of the pancreas is called the
head, the middle of the pancreas is
called the body, and the end of the
pancreas is called the tail of the
pancreas.
It has a tube running through it, which we
call the main pancreatic duct.
And these have got little small tubes
called branch ducts, which
bring one of the things that the pancreas
makes pancreatic juice
into the main pancreatic duct, and then it
flows into these
small bowel or the duodenum where is helps
you digest your food.
Pancreatic cysts are like a balloon.
They’re, it’s filled with fluid, and it
can occur
in the top or the head of the pancreas.
Or you can have a cyst in the body or in
the tail.
In some people, you can have several
cysts.
For example, you can have three or four
cysts in the
tail, and sometimes you can get multiple
cysts throughout the pancreas.
You can have a cyst in the tail, the body,
and the head of the pancreas.
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We are seeing more and more people
with what we call incidentally found
pancreatic cysts.
And what I mean by this, is they
went into a hospital for an entirely
different reason.
For example, they had blood in their in
their
urine and their doctors were worried about
a kidney stone.
They had a scan, and they happened to find
the pancreatic cyst.
And one of the reasons that this is, is
occurring is
that people are getting more and more
scans done more frequently.
So if you go into the emergency room for
any cause, you often get a CAT scan.
The CAT scans and MRI scans are getting
better, and therefore picking up more
pancreatic cysts.
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The first question we ask is when somebody
comes to the
pancreatic cyst clinic is what type of
cyst do they have?
And the reason that that’s important to
try and
work out what type of cyst that a patient
has is because it determines firstly what
is their
management, and how do we look at the
cyst.
And secondly what is the risk of it
developing into a cancer.
The commonest type of cysts that you’ll
see in
the pancreas is a thing called a
pancreatic pseudo-cyst.
And this occurs in people who have had
pancreatitis.
It has no risk of ever developing into
pancreatic cancer.
And usually just needs to be watched and
often resolves by itself.
There are several other different types of
cysts that you can get in the pancreas.
One type is called a Serous cyst this is
common in
women, and has a very low risk of ever
developing into cancer.
There’s a third type of cyst which we call
mucinous cyst, and this is because
the fluid inside the, the cyst is thick
and gloopy or mucinous.
And these type of cysts are, have got a
risk of developing into cancer.
So it’s very important that we identify
people
who have, who have these type of cysts.
And that we follow them, or if necessary,
remove the cyst to prevent somebody
developing cancer.
One of the types of cysts that are
precancerous are called an introductal
papillary mucinous neoplasm, or an IPMN
for short.
There are three different types of IPMN’s.
One type effects the main pancreatic duct,
which
is the tube that runs through the
pancreas.
And this has got a very high
risk of developing or changing into
pancreatic cancer.
The risk in series is between up is
between 50 to 70%.
And that’s such a high risk that people
who, in whom
we think may have a main duct IPMN should
undergo surgery.
The second type of IPMN is called a branch
duct IPMN.
And that’s where one of the small side
branches gets larger and develops into a
cyst.
This is also a precancerous type of cyst,
but
the risk of it developing into cancer is
much lower.
Series say that it’s somewhere between 15
to 20%.
Thus, not all, a very small number of
people
with these branch duct IPMN actually
change or develop cancer.
But these types of cysts need to be
followed so that we, if
a cyst is changed and we pick it up, and
those people undergo surgery.
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There are several different tests that we
can use to look at a pancreatic cyst.
We can use abdominal imaging for exa, for
example
CT or MRI, and we can also use endoscopic
ultrasound.
That’s like an upper endoscopy.
It’s where we put a small camera down into
the stomach.
Which has an ultrasound probe on it, and
the ultrasound waves pass through
the stomach and into the pancreas, and
generate beautiful images of the pancreas.
This is probably the best test to look
within the panc, within
the cyst to make sure that there’s nothing
changing within the cyst.
And it also allows us to put a tiny needle
in, and take
a sample of the lining of the cyst, and
also of the cyst fluid.
The best test that we currently have for
differentiating what
type of cyst we’re dealing with is called
cyst fluid CEA.
It’s good in that it has an accuracy of
78%, but it’s not perfect.
One of the things that we need is we need
better tests
to tell us firstly, what type of cyst are
we dealing with.
Is this a type of cyst that has
a cancerous potential and needs to be
followed?
Or is this a type of cyst which has a very
low or
no cancerous potential, in which case it
doesn’t need to be followed as closely.
And secondly, what in those type of cysts
which are precancerous, which
are the ones that are likely to change or
develop into cancer.
This is something that we’ve been working
on at Johns Hopkins.
Dr. Vogelstein and colleagues have
recently published a paper which
showed that two genes are altered and
mutated in people with IPMN.
But are not [INAUDIBLE] changed in people
with cirrhosis.
And this, these tests appear to be of far
higher
accuracy than what is currently available
with cyst fluid CEA.
Now, I think that these are very exciting
times.
We need to see if these tests are as good
as we think they are.
But if they are, they may change, alter
the way in which we manage pancreatic
cysts.
Branch duct IPMNs have a small but
definite
risk of changing and developing into
pancreatic cancer.
We know from studies done here at Johns
Hopkins and elsewhere that
the time that it takes for the cyst to
change is quite long.
Study by Dr. Ackerbusio here at Johns
Hopkins showed that in
pancreas cancer, the cancer develops over
many years, as approximately seven.
And therefore we have a long time to
intervene
and remove a cyst before it develops into
a cancer.
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One of the questions that patients always
ask us is, when do you need to go surgery?
Now we have very good guidelines called
the international
consensus criteria which tell us who
should go to surgery.
If you’re having some tips for example the
cyst is
causing yellow jaundice or pancreatitis,
then you need to consider surgery.
We also know that the cyst gets very
large, graze in three centimeters, the
risk increases.
And again surgery should be considered.
Finally, it’s important to look very
carefully
within the cyst and with the imaging
test that we’ve discussed earlier to make
sure that there’s nothing growing within
the cyst.
Which is what we call a mural nodule or a
solid component.
Because again that suggests that this is
maybe changing and surgery needs, should
be considered.
These guidelines seem to be very safe and
it, in people who don’t fulfill
them the risk of there being a cancer
within the cyst is very small.
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The pancreatic multidisciplinary program
because so many people are being
diagnosed with pancreatic cysts consists
of a group of pancreatic specialists.
There is myself.
I’m an interventional endoscopist.
We also have five dedicated pancreatic
surgeons pancreatic pathologists,
as well as dedicated abdominal CT and MRI
specialists.
We meet once a week to review all the
cases of
the patients who are seen at the
Pancreatic Cyst Clinic, and
then come up with a consensus as to what
is the
cause of the cyst, and what our
recommendations are for management.
And we’re very happy to see people who
are, have just been diagnosed with a cyst.
Or people who’ve had it for a while, or
are looking for a second opinion.
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