 Guru is the cystic lesion and I think cystic lesion is a bigger challenge for us Because the incidence if you look at it, you know on autopsies studies 25% of adult pancreas have some cyst On MRI about similar 20 to 25% of pancreas done for other indication will have some cyst Good news is majority of them are benign lesions, but you can have a spectrum of from benign to Malignant lesion majority of lesions now are Musinocystic neoplasm IPMN is the one lesion which is contributing to more pancreatic surgeries At my previous hospital when we looked at our audited our pancreatic resection what we learned in two decades We had doubling in pancreatic surgeries and it was contributed by cystic neoplasm of the pancreas IPMN or MCNs are 60% of those and you're not all of them need surgery and I think Having an idea how do we manage these lesions is where I'm going to drive that point home So let's start with Introductal papillary and musinocystic neoplasm because these are the common lesions You will encounter in your practice now most cystic neoplasm are common in women But IPMNs are more common in men and older men Depending on the location. So these are musin secreting tumors, and I just want to tell you that there is some confusion The duct dilatation or assist is not the tumor Cyst is the musin dilating the ducts Tumor are these small papillary projections along the mucosa, which is secreting musin So depending on where this is if it's involving the side branch, you know, we call it as side branch IPMN, which is Preferentially involving side branch once it involves main duct all of them whether it is a diffuse main duct involvement a partial main duct involvement Or a main duct with side branch involvement all of them follow in come in the category of Main duct IPMN why that stratification is important because risk of cancer is much higher in main duct lesion 60% of main duct lesion at that time of diagnosis will be malignant or will have malignant potential whereas majority of side branch lesions are benign So it's that spectrum. So stratifying them into main duct versus side branch is very important Now this is a very important slide because that drives how we manage IPMN patients IPMN patient go through a spectrum of you know hyperplasia to adenoma then carcinoma to invasive cancer So it's a very predictable slow process So if patient is older we detect a benign IPMN You know, it will take 15 to 20 years for that patient to turn into malignant. So you can easily leave them alone so that type of a Projectory and a slow growth is what is typical of IPMN and this tells you why that one of the celebrity lives so long with IPMN Compared to other two types of pancreatic cancer. So let's look at these two cases to drive that point home So these are patient with the side branch IPMN This is August 2006 You see is Unilocular cyst with slightly thick wall and I will come to that morphological feature later on why that's important That's from 2006 to 2010 minimal change. It's much thicker wall. This is 2016 now It has invasive cancer, which was still resected vessels were not involved. So that's the slow progression on IPMN So if you follow them You can really capture these tumors early on so there is much more safety window to capture them This is another example of a patient who had an IPMN in the Unsignored process in 2006 that is 2011 we can see some solid component and year over time which was missed and here we have a Soft tissue and casing vascular structures. This come down to an important point I mentioned in my first talk is ignore the obvious Look at rest of the pancreas. We focus too much on the Cyst we look at the size of the cyst and we forget that there is a Infiltrative component which is outside. So that's what slow slow process. That's why we can monitor these cases Safely, this is the data from my previous institute where we did a lot of research on IPMN patient The point of this study is small IPMNs less than three centimeter Majority of them benign invasive cancers are uncommon That's why in the guidelines if the lesion is less than three centimeter in asymptomatic patient We can safely monitor these patients Using imaging and the choice of imaging can depend on CTMR depending on the availability of these studies now having given that Perspective on pancreatic cystic lesion, let's come to the guidelines How do we manage the cystic lesion because that's what you're referring physician will ask okay? What does guideline dictates now pancreatic cyst is one? Problem where there are more guidelines than actually types of lesion, you know every country has their own guidelines But I would say two guidelines which are followed one is the American College of Radiology and second is the consensus guideline Those are the two ones that are followed now. There is a lot of commonality between the guidelines I think most guidelines are similar in terms of management, but I will just share some of the differences that exist So first thing you look at is patient at the cyst morphology So the approach this more like a Bosnia classification So where more complexity you see in the cyst more likelihood of malignancy So what is that complexity if lesion is micro macro cyst that means you can see few compartments That raises the risk because it's more likely MCN any time there is a solid component in the cyst There is higher probability of malignancy and it goes without saying any time pancreatic duct is dilated as we discussed earlier It is malignant so in absence of pancreatic duct dilatation if you are looking at cyst morphology macro cyst or solid component is malignant a Thin walled unilocular lesion tends to be benign, but a thick wall lesion is where you worry about those can be malignant So thin versus thick wall is the critical Differentiation for a year. This is a thick wall. Even if there were no septations You will worry about this lesion having a high likelihood of being malignant This is pretty obvious as a solid component then comes another category, which is a micro cystic neoplasm We also call them serocystide nomas most of them are very traditional morphology when in doubt You can really characterize them on MRF CT is not typical So what are the risk features when you're looking at we talked about the cyst problem? We look at mural nodule You know dug dilatation in main duct IPMN dug dilatation and I said it's not the duct Which is problem It is the tumor implants within the duct you need to identify those because surgeons don't do total pancreatic to me What they will do is they will preserve some pancreas. So if you identify tumors here They will do ripple procedure and we'll leave like a few centimeter. They will cut the pancreas They will do frozen section and if it is negative They will just you know leave it at that. So not only dilatation of duct but identifying tumor foci Now we cannot always recognize tiny foci So what surgeons do is they do a pediatric they pass a pediatric Endoscope within the pancreatic duct to look for those tumor foci before they respect Enhancing wall is a bad sign again This is something you need to keep in mind in a cystic lesion anything a sick thick wall or enhancing wall is a bad sign Dug dilatation is obviously these are some features if you see that means it's aggressive lesion This is a busy slide and I will give you the crux of management of pancreatic cystic lesion The first thing I said is symptoms Anytime patient has symptoms which could be attributed to the cyst something has to be done at least minimum at the minimum is aspiration of pancreatic cyst Second thing is cyst morphology if cyst morphology has all those features that I described Which they will intervene more than likely resect or at least biopsy The third thing you have to look at is the pancreatic duct changes if in absence of those if it's an incidental lesion If it's less than three centimeter lesion Those are the ones we follow them and depending on the size if it's less than one centimeter The risk is much lower. That's the interval You know you can have a longer interval for a one to two year follow-up and Maximum five year if everything is stable you leave it alone and as the lesion size goes up your your follow-up interval increases as well So that's the main point of this slide is morphology is bad Symptoms all those things in size greater than three centimeter all those three things are important Now I will emphasize on very important point is More than size it's morphology and again when you're looking at pancreatic cystic lesion Just ignore the obvious look at elsewhere Like these are three cases where we have a large lesion here and they are small lesion So by default you would focus on a larger lesion But when you look at the smaller lesion has a thick Enhancing wall. So this is the highest risk not this one So you will target this lesion for intervention surgery This lesion is also three centimeter. You will focus on the size, but look at the thick irregular margin That is more important. This lesion is also three centimeter You will say oh side branch IPM and less than three centimeter, but look at thick enhancing wall So morphology trumps size so always look at morphology in absence of those and in absence of symptoms Then the size comes in picture. I hope I made that point pretty clear to you all