Cystic tumours of the pancreas and PanIN. Jean-François Fléjou Service d Anatomie Pathologique Hôpital Saint-Antoine, AP-HP, UPMC - Paris 6, France

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1 Cystic tumours of the pancreas and PanIN Jean-François Fléjou Service d Anatomie Pathologique Hôpital Saint-Antoine, AP-HP, UPMC - Paris 6, France

2 Cystic tumours of the pancreas Classically rare : - 5% of pancreatic tumours (?) - 5 to 10% of pancreatic cystic lesions (pseudocysts = 90%) BUT :. More and more often fortuitously discovered (1% of abdominal CT scans). May be malignant or premalignant --> Specific diagnostic and therapeutic issues

3 Classification of pancreatic cystic tumours from Kosmahl et al 2004 Epithelial cystic tumours Benign Intraducal papillary mucinous adenoma Mucinous cystadenoma Serous cystadenoma (micro or macro-cystic) Benign cystic neuroendocrine tumour Acinar cell cystadenoma Dermoid cyst Cystic hamartoma Borderline Borderline IPMT Borderline mucinous cystic tumour Solid pseudopapillary tumour Malignant IPM carcinoma Mucinous cystadenocarcinoma Serous cystadenocarcinoma Cystic pancreatoblastoma Cystic metastasis Malignant cystic neuroendocrine tumour Non tumorous epithelial cysts Congenital cyst Lymphoepithelial cyst Non neoplastic mucinous cyst Obstructive cyst Endométrial cyst Non epithelial cystic tumours Benign (lymphangiomas ) Malignant (sarcomas ) Non tumorous non epithelial cysts Pseudocysts Parasitic cysts

4 Relative frequency of cystic neoplasms of the pancreas Warshaw et al AFC 1997 Kosmahl et al 130 cases 527 cases 418 cases* Mucinous cystic tumors 49% 44% 8% Serous cystadenomas 31% 32% 10% IPMT 11,5% 11% 18% Solid pseudopapillary T 3% 4% 21% Cystic endocrine tumor 1,5% 2% 4% *includes pseudocysts

5 Cystic endocrine tumour

8 Clinical features MEDIAN AGE FEMALE (%) SYMPTOMS HEAD (%) Serous cystadenoma 65 yrs 80 pain + mass +/- fortuitous +++ MCN 60 yrs 90 pain +++ mass ++ fortuitous + IPMN 55 ans 40 acute pancreatitis +++ fortuite ++ Solid PP tumour 25 yrs 98 mass + fortuitous

9 Serous cystadenoma Often fortuitously discovered Pancreatic head in women > 60 yrs Typical microcystic appearence on imaging Benign : no surgery

10 Typical epithelium Serous cystadenoma

11 Serous cystic tumours Atypical forms unilocular «malignant» : serous cystadenocarcinoma, no experience

12 Numerous synonyms (Frantz tumour ) Young female patients Most often benign Large, well limited Suggestive histology, characteristic IHC (β-catenin) Histogenesis still debated 10% malignant cases, no markers: must be removed Solid pseudopapillary tumour

15 Precancerous lesions of the pancreas Cancer of the pancreas = ductal adenocarcinoma Poor prognosis, poorly recognised fisk factors, no mass screening Only 3 recognised precancerous lesions: Mucinous cystic neoplasms (MCN) Intraductal papillary mucinous neoplasms (IPMN) Pancreatic intraepithelial neoplasia (PanIN)

16 MCNs Female, body and tail Independant from the ductal system Uni or multicystic (cysts >2cm) Various histogenetic hypotheses Premalignant : must be removed

17 MCNs 2 components Epithelial with varied atypias: from benign to malignant with invasion Mesenchymal «pseudo-ovarian» underlying stroma

18 IPMN - definition Abnormal proliferation of the epithelium from a pancreatic duct, secreting mucus, leading to duct dilation Adenoma, borderline, in situ carcinoma, invasive adenocarcinoma (WHO) Hruban, 2004

19 Papillomatosis Villous adenoma Papillary adenoma Adenomatosis Mucin hypersecreting tumor Intraductal papillary tumor Mucinous ductal ectasia Ductectatic mucinous cystadenoma Identical ductal cell Identical risk of malignancy WHO (1996): INTRADUCTAL PAPILLARY MUCINOUS TUMOR (IPMT)

20 Wirsung / secondary ducts

21 IPMN Pancreato-biliary Intestinal Oncocytic Gastric MUC1 MUC2 MUC 5AC malignant SD +++

26 IPMNs : main questions To diagnose? EUS + punction: moderate sensitivity and specificity Benign or malignant? risk factors: main duct, major dilatation, mural nodule Topography and extension? frozen section +++ Prognosis after resection? benign: excellent! malignant: better as ductal adenocarcinoma Surveillance, no surgery?? small size, secondary ducts, asymptomatic

27 IPMN / PanIN Hruban, 2004

28 Comparison PanIN - IPMN PanIN IPMN Clinical Dg No Yes Visible on macroscopy. No Yes Mucin visible on macro No Yes True papillae No Yes MUC2 + No Yes Loss SMAD4 30% PanIN3 Rare Assoc. Mucinous AK No Yes Hruban et al, Am J Surg Pathol 2004

29 «Lesions» of small pancreatic ducts have been described for a long time: Sommers Gastroenterology 1954 «pancreatic duct hyperplasia and cancer» Confusing terminology lesion, metaplasia, hyperplasia, dysplasia, neoplasia Significance still unclear Preneoplastic, paraneoplastic, nothing to see with cancer Pancreatic intraepithelial neoplasia «PanIN» Hruban et al, Am J Surg Pathol 2001 and 2004

31 Nal 1 2 3

32 Ductal extension, to distinguish from PanIN

33 IPMN

34 Molecular sequence // morphological sequence

35 PanIN Diagnostic reproducibility (Hruban et al, Am J Surg Pathol 2001) 35 cases, before and after consensus between 8 experts Before : 70 designations, 4 classifications After : Consensus 5 pathologists 27/35 cases, 6 pathologists 17/35, 7 pathologists 10/35 Kappa : 0.43 (PanIN-1), 0.14 (PanIN-2), 0.42 (PanIN-3)

36 Frequency of PanIN PanIN PanIN-3 Normal pancreas 16% 0% Pancreatitis 60% 4% Cancer 82% 40% Andea et al, Mod Pathol 2003 Very high frequency in asymptomatic patients with a strong family history of pancreatic cancer Brune et al, Am J Surg Pathol 2006

37 Mucinous cystic neoplasms: distinct pathway J Hepatobiliary Pancreat Surg 2007

39 Ponction PSEUDOCYST SEROUS CYSTADENO- MA MUCINOUS CYSTADENO- MA MUCINOUS CYSTADENO- CARCINOMA Amylase high low variable variable Ca 19-9 variable low high high CEA variable low high high Ca 72-4 low low high high Ca 15-3 low low low high Mucins M1 variable low high high

40 Conclusions Cystic tumours of the pancreas are a specific subgroup of pancreatic tumours They represent rare examples of pancreatic precancerous lesions (MCN & IPMN) IPMNs (macroscopic lesion) may be difficult to distinguish from PanIN (microscopic lesion) PanIN probably represents an important preneoplastic lesion of ductal adenocarcinoma of the pancreas It is important to diagnose and treat these lesions, especially in patients at high risk of pancreatic cancer

41 Diagnosis?

42 Lymphoepithelial cyst

Cystic Neoplasms of the Pancreas: A multidisciplinary approach to the prevention and early detection of invasive pancreatic cancer.

This lecture is drawn from the continuing medical education program Finding Hope: Prevention, Early Detection and Treatment of Pancreatic Cancer, Nov, 2011. Robert P. Jury, MD Cystic Neoplasms of the Pancreas: