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Pancreatic Incidentalomas: Review and Current Management Recommendations Published online: 03.10.2019 THIEME 6 PancreaticReview Article Incidentalomas Surekha, Varshney Pancreatic Incidentalomas: Review and Current Management Recommendations Binit Sureka1 Vaibhav Varshney2 1Department of Diagnostic and Interventional Radiology, All India Address for correspondences Binit Sureka, MD, DNB, MBA, Institute of Medical Sciences, Jodhpur, Rajasthan, India Department of Diagnostic and Interventional Radiology, All 2Department of Surgical Gastroenterology, All India Institute of India Institute of Medical Sciences, Basni Industrial Area, Medical Sciences, Jodhpur, Rajasthan, India MIA 2nd Phase, Basni, Jodhpur 342005, Rajasthan, India (e-mail: [email protected]). Ann Natl Acad Med Sci (India) 2019;55:6–13 Abstract There has been significant increase in the detection of incidental pancreatic lesions due to widespread use of cross-sectional imaging like computed tomography and magnet- ic resonance imaging supplemented with improvements in imaging resolution. Hence, Keywords accurate diagnosis (benign, borderline, or malignant lesion) and adequate follow-up ► duct is advised for these incidentally detected pancreatic lesions. In this article, we would ► incidentaloma review the various pancreatic parenchymal (cystic or solid) and ductal lesions (congen- ► pancreas ital or pathological), discuss the algorithmic approach in management of incidental ► pancreatic cyst pancreatic lesions, and highlight the key imaging features for accurate diagnosis. Introduction MPD. The second aim is to further classify the lesion into benign or malignant. Various cystic and solid incidentalomas The term “pancreatic incidentaloma” (PI) refers to those in the pancreatic parenchyma are listed in ►Table 1.7 lesions in the pancreas that are diagnosed incidentally when obtaining an imaging study of the abdomen not intended to Incidental Cystic Pancreatic Tumors look for a pancreatic pathological process.1 This phenomenon is not new to the pancreas and has been quite often observed Most incidental cystic pancreatic lesions are benign.8,9 The in other organs such as adrenal glands, thyroid, parathyroid, first step is to differentiate these cystic lesions from pan- pituitary, liver, prostate, and kidneys. The first case of PI was creatic pseudocysts. Serous cystadenoma, mucinous cys- described by Kostiuk in 2001.2 Incidental pancreatic cysts are tic lesions, and intraductal papillary mucinous neoplasms frequently encountered now due to advancements and easy (IPMNs) account for more than 90% of primary cystic pan- availability of imaging. The reported incidence of incidental creatic tumors.10 Most of the patients are asymptomatic at cystic pancreatic lesions varies, depending on the imaging the time of presentation. Symptomatic patients may present technique used. In computed tomography (CT), the preva- with abdominal pain, jaundice, weight loss, and/or recurrent lence varies from 0.5 to 3%, whereas in magnetic resonance episodes of pancreatitis. Morphological classification of cys- 3,4 imaging (MRI), this prevalence increases to 18 to 19.6%. In tic lesions of the pancreas is given in ►Table 2.11 a postmortem study by Kimura et al, cysts less than 1 cm in size were detected in 24% of cases.5 Recent published studies Unilocular Cysts have shown that the incidence of incidental PI is rising.6 Pancreatic pseudocysts are the most commonly encoun- When a PI is encountered, the first aim is to classify tered unilocular cysts. Others include mucinous and serous whether it is a pancreatic parenchymal or ductal lesion. PIs cystadenoma, lymphoepithelial cysts, retention cyst, devel- in the pancreatic parenchyma can be either cystic or solid. opmental cyst, epidermoid cyst in intrapancreatic spleen, Incidental lesions in the main pancreatic duct (MPD) can be endometrial cyst, and cystic neuroendocrine tumor or congenital variations or a pathological process involving the an infectious cyst (►Figs. 1 and 2). A unilocular lesion in DOI https://doi.org/ ©2019 National Academy of 10.1055/s-0039-1694074 Medical Sciences (India) ISSN 0379-038X. Pancreatic Incidentalomas Surekha, Varshney 7 Table 1 Pancreatic incidentalomas7 Table 2 Classification according to imaging morphology11 Exocrine Infections Unilocular Microcystic Benign Mycobacterium avium Pseudocyst Serous cystadenoma SCN complex Cystic neuroendocrine tumor Microcystic variant MCN Mycobacterium tuberculosis Unilocular serous cystadenoma of ductal IPMN Rare and atypical fungal Unilocular mucinous adenocarcinoma Mature cystic teratoma and viral infections cystadenoma (very rare) Borderline Retention cyst Mesenchymal tumors Mucinous cystic tumor Developmental cyst with moderate dysplasia Kaposi’s sarcoma Epithelial cyst Intraductal papillary muci- Lipoma Lymphoepithelial cyst nous tumor with moderate Lymphangioma Epidermoid cyst in intrapan- dysplasia Pancreatic Castleman’s creatic accessory spleen SPN disease Endometrial cyst Malignant Pancreatic hamartoma Infectious cyst Ductal adenocarcinoma Schwannoma Macrocystic Cystic transformation Osteoclastlike giant cell Teratoma of the pancreas tumor Metastases Serous Mucinous cystadenoma Dysontogenetic cyst cystadenocarcinoma Colon, breast, lung, lym- BD-IPMN Cystic fibrosis Mucinous phoma, melanoma, renal Oligocystic serous cystadenoma Disseminated serous cystadenocarcinoma cell carcinoma Lymphangioma cystadenoma IPMN Lymphoepithelial cyst Congenital syn- Acinar cell carcinoma Infectious cyst dromes such as von Pancreatoblastoma Duplication cyst Hippel–Lindau’s Solid pseudopapillary Mesothelial cyst disease, polycys- carcinoma tic kidney disease, Ampullary Ivemark’s syndrome, adenocarcinoma trisomy 13 or 15, Meckel–Gruber’s Endocrine Nonislet cell tumors syndrome Gastrinoma Adenosquamous carcinoma Cyst with ductal Multifocal Glucagonoma Anaplastic tumors communication GRF-secreting tumor Colloid carcinoma Insulinoma Granulocytic sarcoma IPMN BD-IPMN PP-secreting tumor Leukemia Collections postpancreatitis Pseudocysts Somatostatinoma Lymphoma as a part of disconnected duct Serous cystadenoma VIPoma Primitive neuroectodermal syndrome Neuroendocrine Serotoninoma tumor Retention cyst/squamoid cyst tumor Developmental cyst Cystic lesions Inflammatory Epithelial cyst Benign pancreatic cysts Eosinophilic pancreatitis Solid cystic Dysontogenic cysts Focal pancreatitis Hydatid cyst Inflammatory myofibro- SPN Cysticercosis blastic tumor Pancreatoblastoma LECs Lymphoid hyperplasia Cystic metastasis Pancreatic dermoid cysts Wegener’s disease Cystic degeneration in solid tumors Retention pancreatic cysts Xanthogranulomatous Malignant transformation in cystic tumors pancreatitis Metastases Hemorrhagic pseudocyst Congenital Abbreviations: BD-IPMN, branch-duct intraductal papillary mucinous Congenital cyst neoplasm; IPMN, intraductal papillary mucinous neoplasm; SPN, solid Epidermoid cyst in IPAS pseudopapillary tumor. Abbreviations: GRF, growth hormone releasing factor; IPAS, intrapan- creatic accessory spleen; IPMN, intraductal papillary mucinous ade- noma; LEC, lymphoepithelial cyst; MCN, mucinous cystadenoma; PP, pancreatic polypeptide; SCN, serous cystadenoma; SPN, solid pseu- Microcystic Lesions dopapillary tumor; VIPoma, pancreatic neuroendocrine tumor that The most important differential diagnosis of a microcys- secretes vasoactive intestinal peptide. tic lesion in the pancreas is serous cystadenoma. It usually demonstrates a polycystic or microcystic pattern consisting a patient with a clinical history of pancreatitis is almost of cysts up to 2 cm in size. They are usually lobulated. The always a pseudocyst. A lobulated unilocular cyst located septa and wall may show enhancement (►Fig. 3). A stellate in the head of the pancreas should raise the suspicion of a pattern of calcification is visible in 30% of the patients and is serous cystadenoma. considered a characteristic of a serous cystadenoma.12 A rare Annals of the National Academy of Medical Sciences (India) Vol. 55 No. 1/2019 8 Pancreatic Incidentalomas Surekha, Varshney Fig. 1 A 43-year-old-female with incidentally detected lymphoepithelial cyst postcholecystectomy in the pancreas. (A) Axial T1-weighted magnetic resonance imaging showing unilocular cystic lesion, which is mildly hyperintense in the head of the pancreas (B) and hyperintense on T2-weighted images (C), showing bright signal on diffusion-weighted imaging (D) with no enhancement on T1-weighted postcontrast gradient echo images. Fig. 2 A 60-year-old male with incidental cystic pancreatic neuro- Fig. 3 A 68-year-old-female with incidental serous cystadenoma. endocrine tumor. Axial postcontrast T1-weighted image showing Axial contrast-enhanced computed tomography image showing poly- incidental unilocular cystic lesion (arrow) in the tail of the pancreas, cystic lesion in the head of the pancreas (arrow) with thin internal showing peripheral arterial enhancement suggestive of cystic neuro- septations in a case of serous cystadenoma. endocrine tumor. cystic neoplasm.14 A peripheral eggshell calcification is high- differential diagnosis of a microcystic lesion in the pancreas ly suggestive of a potentially malignant mucinous cystic neo- is a microcystic variant of ductal adenocarcinoma.13 plasm.15 Other differential diagnoses of macrocystic lesions in the pancreas are lymphangiomas, lymphoepithelial cysts, Macrocystic Lesions infectious cysts, mesothelial cysts, and duplication cysts. Mucinous cystic neoplasms (cystadenomas) and branch- duct (BD) IPMNs usually present as macrocystic lesions. Cyst with Solid Component (Solid Cystic)
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