Incidental pancreatic cyst
Differential
 Neoplastic vs. inflammatory
 Inflammatory – pseudocyst
 Neoplastic
o Benign - SCN (serous cystic), lymphoepithelial, simple cysts
o Malignant potential - IPMN, MCN (mucinous cystic), solid pseudopapillary,
serous neuroendocrine (pNET)
Workup
 H&P
o Often incidental, but on complete history, subtle findings
o Abdomen/back pain (duct obstruction, inflammation, pressure), pancreatitis,
exocrine failure (steatorrhea, weight loss, malnutrition, cachexia), endocrine
weight loss (new onset diabetes)
 Imaging
o CT or MRCP w/ gadolinium and secretin
o EUS w/ FNA
o ERCP w/ ductoscopy – for main duct dilatation
 Cystic fluid cytopathology (highly specific, not sensitive), biochemical (amylase increased
in ductal connectivity - IPMN or pseudocyst; CEA> 192 predictive of MCN, not
malignancy determination), molecular (DNA- KRAS elevation)
 Serum studies - CA 19-9 & HbA1c predictive of malignancy; Alk Phos – biliary
obstruction,
Diagnosis & Tx
 Side branch IPMN - 10-20% risk cancer
 Main duct IPMN - 50-60% risk
 Management hinges on oncologic risk stratification
o Young patient, main duct involvement, mural thrombus, concerning cytology
support surgical intervention
 Resection complicated by fact that IPMN usually multifocal.
Surgical approach
 Minimally invasive distal pancreatectomy w/wo splenectomy. Administer vaccines
preop. Periumbilical camera port, two more working ports on either side. Explore for
metastatic disease. Enter lesser sac, identify splenic artery, may need to use
laparoscopic ultrasound. Develop plane along inferior pancreas. Identify and vessel loop
splenic vein & artery. Try to preserve spleen and vessels – superior outcomes per case
control studies. Do not preserve for malignant vascular invasion (duh). If soft pancreas
use stapler, if thick or firm pancreas use energy device, followed by oversewing. Place
closed suction drain. Follow amylase to guide drain removal.

Special considerations – For positive margins in main duct IPMN: in fit patients resect
more pancreas to total pancreatectomy if necessary. In unfit patients resect more if
possible, but weigh risk/benefits of total pancreatectomy. In side-branch IPMN remove
most threatening lesions, if positive margin/multiple lesions may leave in unfit
patients/reassuring radiological characteristics.
Postoperative management
 15-25% pancreatic fistula rate, may present late, even after discharge. Look for
tachycardia, delayed return of bowel function, abdominal pain.
 Long term survival dictate by status of remnant gland, pathology of primary lesion
o Unifocal, low grade, radiologically -ve/+ve remnant
 Yearly H&P, CT/MRCP, serum studies
o High grade dysplasia, +ve low grade main duct margin, new lesion in previously
negative remnant
 At least biannual H&P, CT/MRCP, serum studies
 At least annual EUS-FNA w/ cytopathology to monitor recurrence or
progression