Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Management of Pancreatic Cysts. My name is Marilyn Almodore, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session as interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit your question. Please note that this presentation is being recorded and will be posted within two business days on GI Leap, ASG's online learning platform. You will have ongoing access to the recording in GI Leap as part of your registration. Now it is my pleasure to introduce our GI Fellow Moderator, Dr. Rebecca Huang, from the University of Virginia Medical Center. I will now hand this presentation over to Rebecca. Thank you. Thank you so much for that introduction. Hey, everyone. My name is Rebecca Haug. I'm a current second year fellow at the University of Virginia. I'm really excited to introduce our remaining lineup of gastroenterologists, very strongly representing the University of Virginia today. First, I have the pleasure of introducing our content expert, Dr. Vanessa Chammy. Dr. Chammy is a nationally and internationally known interventional endoscopist with a particular specialty in endoscopic ultrasound. She completed her internal medicine residency and gastroenterology fellowship here at UVA, and then subsequently completed her advanced endoscopy fellowship at the University of Chicago. She's currently a professor of medicine at the University of Virginia, where she also serves as the section chief of interventional endoscopy. Dr. Chammy is a former ASGE counselor on the governing board, and a recent recipient of the ASGE Distinguished Educator Award. Moving on to our panelists for today, first up is Dr. Ross Bierlin. He completed his internal medicine residency and chief resident year at the University of Virginia. He remained at UVA for his gastroenterology fellowship, and then stayed at UVA for his interventional gastroenterology fellowship year as well. He's currently faculty as an assistant professor of medicine. Dr. Bierlin performs ERCP and EUS, and has a special interest in pancreatic cysts. He's actually published several papers on the topic, and recently taught the masterclass on pancreatic cysts at DDW last year. Next in our lineup is Dr. Alexander Podboy. Dr. Podboy completed his residency at Mayo Clinic, followed by his GI fellowship at Stanford, and interventional gastroenterology fellowship at Cedars-Sinai in Los Angeles. After completing his training, we were fortunate to have Dr. Podboy join us as faculty at the University of Virginia, where he currently serves as an assistant professor of medicine. His clinical focus includes endobariatrics and third space endoscopy. Finally, Dr. Mark Redlinsky. Dr. Redlinsky completed his internal medicine residency and general GI fellowship here at the University of Virginia, where he currently serves as clinical faculty and our interventional gastroenterology fellow. Dr. Redlinsky will be joining faculty as an interventional endoscopist at Vanderbilt University this upcoming July. His clinical interests include interventional EUS, endohepatology, and bones. So thanks for being here today. We're really excited to have this amazing panel talk to us about pancreatic cysts. I'll be monitoring the chat, so please post any questions that you have. And with that, I'll turn it over to Dr. Shammi and Dr. Bierlin. First, I want to tell you that we're all content experts here. So it's not just me, it's everybody on this panel. And I also want to tell you that Rebecca is outstanding, and we're fortunate enough to keep her on faculty, which is exciting. So these are briefly the learning objectives. You can read them there. We'll go to the next slide. So why are we even discussing pancreatic cysts? You know, they go on to cancer, and patients are extremely anxious about this. And so are we as physicians. We know that pancreatic cysts are on the rise. And part of that's because, you know, the population is aging. In fact, by the time you're 80, 37% of people will have pancreatic cysts. Now the majority of them, you know, are asymptomatic. We know that imaging is better, and we're doing it more frequently. So cross-sectional imaging is such a CT and MRI. And it's a question of whether the incidence is actually rising. We also know that there are multiple guidelines, which all differ slightly on how to survey these precancerous cysts. And so sometimes there's confusion about the workup and the management of these lesions. And we're hoping that by the end of this hour and a half, we can make things a little bit more clear and easier to negotiate. So when you're thinking about different pancreatic cysts, think of the following. You know, does the patient have a history of pancreatitis? Because if they do, one can consider maybe pseudocyst, right? You also want to look at the morphology. Is it macrocystic, like mucinocystic neoplasms? I think of M, you know, macrocystic, mucinocystic neoplasm. Or is it microcystic, small, like a cirrhosis adenoma? Is there communication with the pancreatic duct, which would make the amylase high? And that's important because IPMNs and pseudocysts do communicate with the pancreatic duct. Obviously, cytology matters. And fluid analysis, which in addition to cytology, includes CEA, which we know is, I think, of 200 is easier to remember, is over 200 in mucinous cysts, such as the IPMNs and the mucinous cystic neoplasms. Glucose level is brand new, and we'll talk a little bit about that. You know, glucose level of less than 50 is, in many studies, better predictor of mucinous cysts than even CEA, and like we talked about, cytology. So with that, I have the pleasure of, you know, Ross really put a lot of time into these cases, and we're excited to share them with you. So go ahead, Ross. Yeah, we're real excited to show you these cases, and hopefully these cases will be illustrative of some of the most important points of how we work through these pancreatic cysts and how we think through them. I think maybe we all approach things a little bit differently, and again, with there being variations amongst the different guidelines, it can make the workup a little confusing. And when one tries to put together all of the different guidelines and how do you interpret them, it can be sort of daunting. But I think if you take a step back and see the forest for the trees, you'll realize that there are some pretty significant similarities between the guidelines, and that's where the important details are. So we'll start with a few cases, and I'll ask our other content experts here to help us with how they would think through things, what would be their next steps. So the first case is a 62-year-old lady who was initially seen for pancreatitis in 2019 in another state. And at that point, looking through her record, she had an imaging study that showed a 7-centimeter pancreatic cystic lesion. The etiology of her pancreatitis was unclear. Her workup was pretty unremarkable. They did an endoscopic ultrasound and sampled the cysts. And again, this was at the other facility, but the CEA was quite elevated. The amylase was also very elevated. And their description of the fluid was thin and Coca-Cola colored. From their notes, they said this is most likely a pseudocyst, and they did not recommend any follow-up. She moved to our state and was referred to me for a second opinion on this. And this was relatively recently. So I got a scan for her. This is in November. And here you can see a large cystic lesion emerging for what appears to be the body and tail of the pancreas. And when I look at these lesions, you know, I want to see, like Dr. Shamian mentioned, I'm thinking, what's the morphology of these? Is it a collection of a bunch of little cysts, meaning it's microcystic, or does it seem to be macrocystic, meaning one larger cyst? And in this case, it looks to be one larger cyst. And there can be some thin, you know, you can sort of start to see some thin, wavy septations in this. And that's what made me think, well, maybe this really isn't a pseudocyst. These septations can be seen occasionally in pseudocysts, but would be relatively atypical in appearance for a pseudocyst. And so with that, you know, I started thinking about the differential and what sorts of things could this be. Certainly, pseudocyst is on my differential, but when I thought back to the case that from the endoscopic ultrasound that they had done, the CEA was very elevated. And then putting that together with these septations that I was seeing, I just said, you know, I'm not sure that this is a pseudocyst. And all of the things listed here were on my differential. And so, you know, with this one, there's no big surprise. I went ahead with endoscopic ultrasound, which I'll show you. But, you know, the question actually, when it was posed to me for a second opinion was for a cyst gastrostomy. And that can be a very easy trap, I think, to fall in is to just to go ahead and, you know, they had a history of pancreatitis, and they've got a cyst. So go ahead and do a cyst gastrostomy. And I think, you know, for me, I wanted to make sure I knew exactly what we were going to be draining. On endoscopic ultrasound, you can see pretty clearly here that there's a large cystic lesion. You can see the transducer here. So you can appreciate how magnified out this is. But it's a large cystic lesion. You can see a nice representation of all the septations. And you can see what the fluid looks like over here. It was relatively thin. And I don't show a picture of this, but there's something called the string sign. And that's if you were to put a drop of fluid between two gloved fingers or between two glass slides and pull them apart, if that string is longer than 3.5 millimeters, that's been shown with very high accuracy to represent a mucinous lesion. And this one, the fluid seemed relatively thick and certainly had a positive string sign. So interestingly, the amylase for this was very low, and the CEA was quite elevated. I did send it for genetic testing. And again, which I'll show you, but the glucose is very low. They do comment that mucin is present. And there are not any GNAS or KRAS mutations, which we can discuss later. Often, these are seen in mucinous lesions. But it's important to note that here, the quality of the DNA was low or poor, and it was very degraded. So it's sort of hard to interpret that. But when... Ross, sorry to interrupt. I just had a quick question. Yeah, please. When you posed the case, the amylase was quite high, I think, you had mentioned. And they also described the fluid as thin Coca-Cola colored, which doesn't appear like the fluid looks like that now. What do you make of that? Or do you think they sampled the same thing? Yeah, it's unclear to me if this was... You know, you can get a pseudocyst that once it isolates itself off, that amylase sort of drops away. But a fresh early pseudocyst will definitely have a high amylase. Perhaps the patient had a pseudocyst, and they sampled that, and they did not sample this lesion. It can be hard to know if you've got several cysts neighboring each other, you know, which one to sample, and are they all the same thing? You know, I didn't have the luxury of seeing the EUS images from back then. And it's really hard to kind of retrospectively quarterback somebody else's EUS and what they saw and what they did. And, you know, one of the things I've learned is EUS is very difficult. And, you know, the more of these that you do, the more of them you learn just how difficult it can be sometimes. But, you know, from my standpoint, you know, things just weren't sort of adding up. And the last part I'll add is the fluid markers aren't perfect. We have a case later that I'll show you where, you know, they're confusing, and I don't think they added up clinically to what it was. So, Ross, can I ask you a question? Sometimes, too, if there's bleeding in it, it can look a little darker. So that may be potentially a reason. But everybody on the panel agree with the endoscopic ultrasound? Just curious. Alex and Mark, I think Mark agrees. But, Alex, any... I think what's hard is always knowing whether or not your cyst is a sequelae of pancreatitis or is the cause of pancreatitis, right? And I think in this case, for a pseudocyst that's lasted for three years, I think your index of suspicion really has to be elevated that potentially maybe this is something that's driving or something, you know, subsequent. The fact that it didn't involute and it's seven centimeters in size, I think you really have to be on your index of suspicion for potentially that, one, is there a malignancy, or two, like a pre-malignant condition? And I think how I was trained was always, you know, mother-daughter or grandmother-type cysts, right? And she's right in that mother kind of cyst area that you need to be on the idea that potentially this is a nuisance, an aplasia. I did want to ask and pose to Ross and Vanessa, you know, one man's three and a half centimeters is another person's, you know, two and a half centimeters. How often are you guys doing string tests clinically? You know, depending on how much fluid I can get, if I have enough fluid to send off, and I think I can get all my analysis done with that amount of fluid, then I almost always am taking at least a drop and putting it between my fingers and just sort of feeling it and seeing what it looks like and getting an idea. It can be hard for the cytologist to definitively say, you know, very clearly there's mucin here. And sometimes they outright call it and sometimes they don't comment on it at all. And if you ask them about it, they'll say, oh, yeah, there's mucin here, but I didn't comment on it. And so, you know, sometimes what they think about, you know, we don't think about or vice versa. But, yeah, if I have enough fluid, I'm personally always do it just to kind of get a better sense of what kind of fluid I'm dealing with. And as the interventional fellow, I can honestly say I've seen Ross do the most string test signs. So it has been helpful. Yeah, sometimes and I agree with you guys, you know, maybe I'm a little bit more on the lazy side, but sometimes when it's really thick and you pull back and you can't get fluid, once you stick the stylet back in there, you like this big glob of snot comes out onto the slide. And so when that happens, you kind of know it's mucinous. But I think it's a very easy test, what Ross is describing, and I think important if you're looking for mucin. We have a question from the chat. Would you ever think about doing a contrast EUS and more a biopsy to characterize for wall dysplasia in this case? So I can tell you that contrast EUS, I've tried it a couple of times for solid lesions. I'm not really sure that we have great data that it's going to help for cystic lesions. And the more a requires a 19 gauge needle. So for something in the body or tail, I think it's very reasonable to use to try to get the epithelium and a diagnosis in the incident in the head. It's a little tougher. You can get bleeding and you can get pancreatitis. You know, we tend to not use it as often as some institutions actually just presented a DDW with somebody at the Yale University, and they don't tend to use it very much either. So I think it's a little bit of preference. I don't know if anybody on this panel feels like we should be doing it all the time. No, I don't think it should be used routinely. That's a really good question from the chat. You know, I think it should be a tool in your toolbox that you're aware of and that, you know, you can use in instances where, you know, let's say you're not getting the diagnosis and you've tried, you know, other modalities and you're not getting it. The reason I don't use it routinely is like Dr. Shammy mentioned is, you know, quite a bit increased risk with the procedure. I have actually a slide on it later, I think, but around about a 10% risk of bleeding and pancreatitis with it requires you to use, you know, a larger needle than we normally would use. And typically, you know, I just found that we haven't necessarily needed it. You can tell if something's mucinous or not mucinous. And sometimes when a lesion is this size, you know, you always want to answer on EUS is, is there a connection to the pancreas duct? But when something is this big of a space occupying lesion, it can be really hard to tell if it connects to the pancreas duct because it just squashes everything. But yeah, I mean, if you're if it's vital to determine, you know, differences, you can do it. But in general, I tend to shy away from it just from a risk standpoint. And usually we don't need it. So in this case, you know, we do did see a bunch of thick mucin and we did not see any cytological atypia here. And so I just quickly wanted to touch on this, which Dr. Shamian mentioned, the cis fluid glucose. There have been a bunch of studies on this, and this was a meta analysis of over 600 lesions. The studies from 2021, and they show that if you look at looking at cis glucose, it's got a very high sensitivity and accuracy, higher than CEA. And it's best if you combine the CEA and the glucose, you know, will give you a better idea. But having a low cis fluid glucose does help determine that it's most likely a mucinous lesion. So in her case, we referred her for a lateral pancreatectomy. Here you can see this is her cyst at the top. This is the spleen that came out with it in a piece of the mesentery. But it's actually pretty interesting, I think, to see this thing outside of the body. It's not something we we get to see a whole lot of. But this thankfully did not show any high grade dysplasia or anything like that. She did really well after the resection. Now, Ross, I know you mentioned the glucose, and I know sometimes our labs are a little hesitant to run like a full gamut of glucose. It comes back kind of not binary as high and low, but they'll get kind of cut off for a frame of reference. My previous institution, we were using a bedside glucometer, but glucometers don't go below like 60. Can you comment on your clinical practice, like what you like to use here? Are you sending that off using the bedside glucometer? What do you guys like? Yeah, it's a funny comment about the bedside glucometer. I just got yelled at the other day by the lab for for using it. I got a nasty email. It was really low, so it worked out well. But it's not designed for that purpose. And most labs require clinical validation of tests before they're going to use them. And so our lab is very strict about that. When I do send my when I send it off, I send it to a third party group for analysis. If I'm sending it a you know, the glucose, if I'm sending other tests and they give me a straight up number on it, which is really helpful. And that's that's validated. But in general, I'm looking for any type of mucinous lesion, either an IPMN or an MCN, cut off of 50. So below 50, it would be considered low and would be a sign that you may be dealing with a mucinous lesion. Ross, I think your answer was outstanding. The other thing, honestly, I think the lab wants to charge. And I think it's a little bit more than just validation, but I think the institution, you know, and I think this is not just our institution, but institutions in general, you know, if you do it at the bedside, it's just a different story than sending it to the lab. Yeah, I do worry a little bit about the bedside glucometer because when I do it, I see, you know, it's meant for blood, which is obviously one consistency, and then I'm putting like a glob of snot into it. And so I just don't know how well it, you know, how validated it is. It's never not told me that it's low. So I don't know, but yeah, every time I do it, I get like a really nasty email from the health system about it. So I sort of shied away from doing it recently. We do have another question from the chat. How important is it to send for next-generation testing, mutation analysis for these patients? And is there extra cost associated with this? Is this something that you guys do routinely? You know, I'll speak to it and I'll get Vanessa's take on it too. I do not routinely send it. The reason is a couple of things. One is I don't typically need it for everyone. I use it for ones where I'm like, you know, trying to answer, and I'm really confused as to exactly what this is, if there's some diagnostic uncertainty, but if it, you know, looks like an IPMN or an MCN and I get the fluid out and it's very thick, and, you know, I'm pretty confident that, you know, I know what we're dealing with and my, you know, amylase and CEA are aligning and everything seems to be pointing at one diagnosis, then I don't necessarily send it for anything else. And when it comes to cost, there often can be additional charges to the patient. It depends on their insurance status and it depends on where you're, the lab to which you're sending it and the nuances of how they handle it. Sometimes they'll deal with it differently for private insurers versus Medicare or Medicaid patients. So you do need to understand the nuances of what you're sending and where you're sending it to for the charges for the patient. And I completely agree with what Ross said. If it's an indeterminate cyst and you're unsure, and this really kind of will sway you one way or the other, surgery or surveillance, I'll do it, but otherwise I'm not sure it's necessary for all cases. Because again, there is a potential cost. The other thing is ask your surgeon, when you guys start your practices, ask the surgeon and say, listen, you know, will this help you? Will this push you to operate or not operate? Because I think that's another important thing. You know, they each have preferences and even amongst our group, our three pancreatic ovulary surgeons differ as to those that really want it all the time and those who do not. So that's another important point. Any other questions about this case or anything? Any other input or thoughts? I think the imaging is classic. You know, it's macrocystic and a beautiful case. Another person in the chat had mentioned that they sampled a walled cyst with the US needle after aspiration of the fluid while suction was turned on. I thought that was an interesting idea. Yeah, and sometimes we'll do that particularly with cystic neuroendocrine tumors is really, you know, the answer is gonna be in the wall and some of those. And, you know, what we're looking at is in where the cancers arise. Remember, it's not the fluid. The fluid is the by-product, right? It's the cancer and the cells are in the wall. And so it's not wrong at all to sample the wall if you can get to it. Most of these don't have, like you can see this, the huge cyst, but the wall itself isn't very thick. And you gotta be careful, you know, unless you know, you should know exactly where the pancreas and the pancreas duct are. I try not to put a needle in through the pancreas duct if I can help it more, unless it's like the only way to get a diagnosis just because of the risk of pancreatitis and pancreas duct leak. But that's, you know, my approach to it. I think that's an important point for those of you, especially when you're starting, really avoid the main pancreatic duct when you're, you know, aspirating these cysts just because of the chance of leak. The pancreas is a very, very moody organ and you do not wanna piss it off is kind of how I approach it. So really, really try to avoid the main pancreatic duct like Ross had just stated. And so just, yeah, quick summary here. So these mucinous cystic neoplasms, MCNs, are a line by columnar epithelium, and that's surrounded by an ovarian type stroma. So that's why they're essentially exclusively found in women and they're gonna be typically middle-aged women, 50s, 60s, and they're typically in the body of their tail. It's not impossible to find them in the head. They do not have a communication with the pancreas duct, which is why their amylase is low and they will have an elevated CEA because they contain mucin. So those are some key kind of takeaway points from this. And when we, this is another picture of MCN or mucinous cyst adenoma. You can see this really mucusy filled cavity here abutting the pancreas. And again, there are some, a thick walled lesion here with lots of thin septations. And you can see the septations well on this EUS image. And then this is an up-close view of the columnar epithelium with that ovarian type stroma that's pathognomonic for this. One additional question from the chat. Should we be sampling every single daughter cyst if coming across a macrocystic lesion? My take is it depends on if it would change the management. So for example, if you've got a large cyst that's in the body or tail of the pancreas and there are a couple other smaller cysts, but you think that the other cysts look similar and you've assessed the most high risk appearing lesion. And let's say you were gonna send that patient for surgery and sampling a smaller cyst next to it wouldn't change anything. And that's all gonna come out at the same time. Then I don't feel the need to sample other cysts. If there's a diagnostic uncertainty of what the neighboring cysts are or if it would significantly change the management if it looked a lot higher risk for maybe there's a mural nodule or some solidarity next to that lesion, then I consider sampling it. But my practice would be to focus on the highest risk appearing one, assuming they all look similar. I don't know what you all. Well, at one point I would say, and then we'll hear from Alex and Mark. If you have multiple cysts, if it's multifocal, it's probably not a mucinous cyst adenoma. It's probably multifocal IPMN. So just keep that in mind as a little kind of trick. Is it impossible? No, but I've never seen anybody with more than one mucinous cyst adenoma in a pancreas. So Alex and Mark, I don't know if you have anything to contribute to that. Just highlighting, I think exactly what you mentioned. And then Ross, as you mentioned, right? Like this patient most likely is going for, I think this is like mid-body. So they're going for pancreatectomy. And so if they have cysts in the tail, it doesn't really warrant assessment or making risk of bleeding or infection or whatever have you. If you know that basically this is the cutoff they're gonna get like a distal pancreatectomy body. I mean, just briefly when you think about how do we manage MCNs and which ones are gonna come out? These are not all of the guidelines, but these are some of the major societal guidelines that are used most frequently. So there are other guidelines that exist just so you're aware of it. But the 2015 AGA and the 2018 ACG, just treat these just like you would an IPMN. The Tanaka guidelines or the 2017 International Consensus Guidelines don't spend a terrible amount of time dealing with MCNs. And they just sort of briefly mentioned that could consider surgery, but relatively treat them like IPMNs. In the 2018 European guidelines, they mostly use a size cutoff that we'll discuss later as similar for IPMNs. So in general, you can sort of, you wanna look for the same risk criteria that we'll discuss later for high risk IPMNs. To the other panelists, are any of you following these with surveillance imaging? Have you had pushback getting these patients into surgery? I'm just curious. I tend to treat them and follow them like they're an IPMN if I truly think it's an MCN. And no, I've had no pushback getting them into surgery or anything like that. I concur. All right, we'll shift gears a little bit to another case. This is an 81 year old guy and he had a history of prostate cancer for which he had radiation therapy. And during the workup for his prostate cancer, they incidentally discovered a 4.1 centimeter cystic lesion in the head of the pancreas. And that was on an MRI dated back to 2011. And so here is his picture of his cyst. So unlike the last cyst, which was macrocystic, this is a microcystic lesion, meaning it's a conglomerate of a bunch of tiny little cysts that are together. You can see on the left image, you can see where the bile duct comes down and on the right image, the pancreas duct, neither of which are significantly dilated or anything like that. He underwent an endoscopic ultrasound. We don't have those images because it dates back to 2011, but that confirmed a multi-septated lesion in the head of the pancreas and it was sampled. And you can see here is the sample fluid analysis. So had an amylase that's not significantly elevated, a CEA that's not significantly elevated. And on cytology, it was just bland epithelial cells. Ross, at this point, I'm curious what everybody thinks on the panel. Mark, what are you thinking in terms of a differential diagnosis? Yeah, a couple of things jump out at me. One is the low CEA. So kind of using that cutoff of 192 or 200 to make it easier, less likely to be a mucinous cyst. And then the cytology showing bland epithelial cells. So you and I, and I've worked with Dr. Podboy and Dr. Bierlein, when we try to stick SCNs, we often get nothing back or blood. So the imaging plus the low CEA plus the cytology are making me lean towards an SCN here. Yeah. Anybody disagree with that? Thanks, Ross. Yeah, and Mark, to your point, that's a really good one about, you know, we always, especially early on, you know, I look at something and I'm like, that's an SCN, but I should probably stick it anyways and try to make sure I'm sure of exactly what I'm dealing with. But it's frustrating because it's a bunch of pockets of tiny little cysts and you get one drop out of each little cyst and then it starts getting bloodier and bloodier. And then you're just like, what am I doing here? And so it can be a really frustrating process, especially when you're looking at it and you're like, why isn't there more fluid coming out of this? And that's sort of also pathognomonic for an SCN, I've found, but that's a good point, Mark. And so, yeah, looking at our diagnosis here, I don't really have much else to add to Mark's thought process. That was great. You know, probably, I was thinking probably not an MCN because again, this was a microcystic, not a macrocystic lesion. I will say branch duct or side branch IPMNs can also have a similar appearance. And so it's easy on imaging to confuse the two, EOS can help kind of clear that up a little bit, but it is, you can sometimes see that quote unquote like cluster of grapes with an IPMN, or if you've got a bunch of little cysts that are together. So you gotta be a little bit careful and then cystic neuroendocrine tumors just typically don't appear that way. We'll discuss about one of them later. For us, one thing I wanna say is, sometimes they confuse you because the cirrhosis adenomas can be oligosystic. So sometimes 20% of the time, they can just be macrocystic. So it's a little bit confusing. I wish they would just follow the rules and then life would be easier. But just to keep in mind, I think it tends to be microcystic the majority of the time and the images that Ross is showing, they're beautiful. Those are the ones we end up, or at least I ended up sticking. And then like, it's exactly what Ross, you mentioned. You're like, why is there only blood coming out? Why is there nothing coming out of these oligosys? It looks just like a mucinous cyst should look, kind of the right demographic, and then nothing comes out, bland epithelium. Everything is kind of boring. I guess more, we all, I think in the fear, right, of misdiagnosis is what kind of drives a lot of us, or at least maybe like early stage investigator and I'm sure as fellows, is the case report of cirrhosis adenocarcinoma that kind of hides within these. And there are less than, I think, 30, 40 cases worldwide. Vanessa, do you have any comments on if there's appearance that's different or driving like a cirrhosis adenocarcinoma versus these classic cirrhosis neoplastic lesions? So I think those, I mean, if you ask our pathologists, they don't go onto cancer. I mean, this is a benign entity and you don't even need to survey them. The only reason some people do is because if they're really large, they grow real quick and they can compress. But I have a feeling if you really went back and look at those series that turned into cancer, it's either extraordinarily rare or really wasn't a cirrhosis adenoma or, yeah, cirrhous tumor. So that's kind of my opinion. And I've asked numerous pathologists about that question. A question from the chat. Are there any features of an SCN that you would wanna refer the patient to surgery? Yeah, we'll discuss that actually a little bit in this case coming up. So I'll hold the surprise for that answer. So we did watch his imaging over time and you can see it grows a little bit over time and just gets a little bit bigger with each subsequent year. And you're probably asking, why are we just watching this thing grow? And that's because I think a lot of patients are like, I can't possibly not watch this. And you're like, well, it's not gonna change our management, but you're also not gonna change their mind. And so at some point, I also have a little trepidation about saying, well, geez, there's a six centimeter lesion in the head of your pancreas and we're not gonna watch it. And at least in the head of the pancreas, I worry is it gonna cause some problems like biliary ductal obstruction or eventually block off the pancreas duct or cause extrinsic compression on the duodenum on a gastric outlet obstruction like picture. It's just in a very high value real estate area in this specific case. But yes, in this guy, we sort of just watched it grow a little bit. And so he did develop progressive pancreatic ductal dilation. You can see that here on the bottom right, how dilated the pancreas duct is. And so surgical resection was offered and because he was symptomatic. And so that's a reason that we would move to surgically remove those in certain patients is if they're causing problems. So in this case, blocking off the pancreas duct or as he subsequently develops is a bile duct obstruction from this more causing others, extrinsic compression on the duodenum or stomach in a gastric outlet or proximal small bowel obstruction picture. So you can see in April, his liver enzyme shot up, his biliary ribbon was 10 and he was admitted with that. Here's a repeat CT and you can see how dilated his bile ducts are. There's intrapanic ductal dilation. His pancreas duct is very dilated. So this is causing a classic double duct sign. And again, surgery was offered and the patient said, thanks, but no thanks. An ERCP was attempted, but the duodenum at this point was quite deformed and even getting into the bile duct was really impossible because of the level of deformity. He ultimately underwent a percutaneous strain and that was subsequently internalized by our interventional radiology colleagues. And so this is a cirrhosistic neoclasm or a cirrhosis adenoma, so SCN or SCA. These are lined by cuboidal epithelium, unlike the mucinous, which were a columnar epithelium. And again, these are, typically you'll see this honeycombing or microcystic pattern. 30% of them or so will have a central scar. So it'll be kind of a bright lesion on imaging. That's really pathognomonic for these, but again, most of them actually do not have that. The majority of these are in women, so about three quarters of them are found in women. Similar to MCNs, they do not have a connection to the pancreas duct, so they have a low amylase, but unlike an MCN, these do not have any mucin, so they'll have a low CEA. In general, we don't need surgery for risk reduction, but like we talked about, if they become symptomatic or cause problems, that would be an indication to consider surgical resection. Any questions or other thoughts from the group on these lesions? I think on the next slide, Ross, if we can, the one thing, I'm kind of simple, so I think of cirrus S, and I think of it as a sponge, if we could press the next. And so this is kind of what it looks like, a C-sponge. It's got a S-central or stellate scar. It's small, microcystic, and I don't have an S for this one, but it's cuboidal. It's lined by cuboidal epithelium, like you can see there, as opposed to columnar, but I think just remember S for the cirrus cysts adenomas. Yeah, like the sponge is a really good analogy, and this is a really good picture of that, and then the scar, the microcystic, lots of little cysts. And so here we're comparing the MCNs and the SCNs. So again, MCNs are macrocystic, SCNs tend to be microcystic. There's no scar associated with MCNs, where there is about 30% in the SCNs. The SCNs are gonna be females only, whereas the MCNs are predominantly female, but certainly can be found in males, but it's, and then actually this should be, sorry, this should be reversed. And then amylase, there's no connection. If amylase, remember, people get all wanting to memorize charts, but I think for me, if you think about it, it makes a lot more sense. So if there's a connection to the pancreas duct, it'll have an elevated amylase. Neither of these do, so they're not gonna be elevated. Similarly with CEA, CEA I associate with cancer, you know, or the thought of a tumor marker. And so a mucinous cyst is a pre-cancerous lesion, therefore in my brain, I connect that to CEA. And so an MCN is going to have an elevated CEA in most cases, whereas an SCN is not, which means there's malignant potential in the MCN, but not the SCN. So two questions from the chat. So first off, is there any specific glucose level that you use as a cutoff for an MCN? And secondly, sometimes the fluid studies, combination of CEA, glucose, amylase doesn't really help in diagnosis and results can be equivocal. CEA can be borderline, maybe glucose is like 40, amylase 200. How do you approach these cases when your combination of results are equivocal? That happens, that's a really good question. I use a, we use a cutoff of 50 for the glucose and it's not at all uncommon for things to, for the fluid analysis to not be out of a textbook. I have a case of that later actually. And like Dr. Shammi mentioned earlier, especially bleeding into the cyst can significantly change things. If your patient's serum glucose is 250 and they bleed into your fluid into the, you get a bunch of blood in your fluid, their glucose is going to be elevated. And those are cases where, you sort of have to ask clinically, if I'm figuring out, is this an MCN versus an IPMN, does it really matter? Is it gonna change my management? Or if it's an SCN versus an MCN, it would. And those would be times where if I've sampled it and I'm not getting something that I'm, I can't answer the question effectively, then I'd move to, what other tools do I have in my toolbox to help answer this? And those are genetic testing. You could consider the Moray biopsy forceps. We don't typically use those, but just understanding what options are out there. And just trying to ask, does it matter? Would it change anything right now? Or would I just still continue to survey this and see if it answers itself in the near future? So if it's a small, low risk appearing cyst, then maybe I just continue to monitor it and see if it gives me a better answer over time. I don't know. Yeah, no, I agree. I think age too, if it's somebody younger, I'm much more determined to get a diagnosis than if somebody is 85 and got COPD. So as much as, I mean, the clinical scenario also really, really matters. And also patient anxiety. Does somebody feel comfortable just kind of following it and not knowing exactly what it is? But I think we need to kind of combine what the lab values or the cyst analysis is. And if it's equivocal, how badly do we need to know? Is it going to make a clinical difference? And I agree with Ross. If it will, then I would do molecular analysis and consider biopsying the wall, et cetera. So very good point, Ross. Yeah, that's a good question. And unfortunately, that clinical scenario happens more frequently than I always thought it would or hoped it would, but it does happen. So in case three, this is a 86-year-old lady who is very active. And I'll preface this with, I don't know, because we're imaging people more frequently and people are getting older. I get these flurries of like six millimeter pancreatic cysts in an 86-year-old patient who comes in and I tell them they don't have pancreatic cancer and I leave with like a hug and a kiss on the cheek. And it's like, how did we even get to this clinical scenario? But it's like I cured their pancreatic cancer, so I'll take it. But anyways, this is an 86-year-old lady who came to me with a 12 millimeter cystic lesion in the body of the pancreas. And there's always a question I think of is, when do you stop caring or stop monitoring for these cysts? And in my opinion, trying to figure out when to stop a colonoscopy in certain patients can be somewhat challenging, but trying to figure out when you tell somebody, we're gonna stop looking to see if your cyst is gonna develop into pancreatic cancer is a real doozy of a conversation in a lot of patients. And some of the guidelines, like the AGA guidelines mentioned a cutoff of age 70. And I think everybody's input and take on this is different. I think it's really, really important before you embark on any surveillance protocol or anything like that is to sit down and tell the patient, hey, we're monitoring these because there's a risk of developing cancer. And if you were to develop a cancer, would you want surgery and or chemotherapy or any type of intervention? And I've had some older patients who said, oh, absolutely not. And then in that case, the answer is easy. It's, well, we recognize that this image exists and that this exists, but we're not gonna, there's no point in further workup or monitoring. However, if the patient's very clearly not a candidate for any type of intervention or chemotherapy or anything due to extensive medical comorbidities, then probably don't need to venture down that road. But this lady, she was 86, very, very active, still runs her own errands, goes to the grocery store, drives all over the place and is very active. So even though she's 86, I did actually say, let's talk about this and let's work it out. So what would you guys do? What do y'all think as a next step? How would you guys individually approach this? This is a tough one. I mean, I think you've, yeah. I think when they're 86, it's a bit of a doozy and you never know. And that's sort of why I put this one in there is that, what do you do at 86? Alex or Mark, what do you guys think? For me, a lot of it is, assisted goes from 0.6 to 1.6, is always way more concerning than assist that's 1.6, 1.6, 1.6, right? And so I think for a lot of these indeterminate, right, these quasi in between, a lot of it is progression, just to see what the change is. And so assist that's changing is concerning, or assist that's kind of changing slowly, but maybe if you sample it, it's got K-RAS and G-RAS mutational, like something like, so more so I think for me, it's marrying some of our societal guidelines and some of the international consensus guidelines. And so maybe I'm just a little bit more likely to sample or like to screen them just to see what that changes and then interval screening. So I think for this lady, I know with how well she is, she probably is a surgical candidate. And if it is changing and moving or somebody we can consider ablation on it, probably warrant assessing. So what's your answer? I think I would do it in six months. That would be my bias. I would probably screen her in six months. MRI in six to 12 months. Yeah, Mark? Yeah, I think I'd pick answer E, which is talk to her and kind of discuss her goals. So I'm skirting the question a little bit. Yeah. The only one that I'm not leaning towards is A, but I think you could make arguments for B through D. And it depends a little bit about how aggressive she wants to be. And if we were to find something, what would we do about it? So what else would you do? Yeah, so I talked to her about those options and I went forward with an MRI in six months. And so her MRI shows a unchanged 12 millimeter lesion in the body, communicated with the pancreas duct, and the pancreas duct upstream from it was 3.5 millimeters. And so we were kind of back at that same question of what do we do? She's like 86 and a half now, but still very, very active and she wanted to follow it. And so I talked with her about that and I did space things out a little bit. I'll tell you for the next one, I push it out to a year. If my practice, and I don't know, I think this is sort of in the guidelines a little bit, but depending on if it's a sub-centimeter cyst, my next imaging may be in a year, but on the index scan, I typically will get another scan in about six months because you only have one data point in that. You don't know what it's doing over time. You don't know what's going on with it. And very often I'm getting, a patient got a CTA of the chest to rule out a pulmonary embolism. And on that, they happened to catch a cyst in the tail of the pancreas. It's partially imaged in a non-ideal imaging modality to assess for it. And so, if it doesn't look high risk and there's nothing that I'm overtly worried about, I'll push it out for six months. My, part of the question I wanted to ask you guys is if you have a preference for a CT versus an MRI, because I think that comes up and that's a question I get asked a lot and when we do these sorts of conferences. And I can tell you my personal bias is to get an MRI with contrast. A contrasted study is very important because you're, it helps to look for, is there enhancement? Is there, do the septations enhance? Is there a mural nodule or solid tissue, like a solid component to the lesion? And those are things you're gonna miss on a non-contrasted study. My other reason for preferring an MRI over a CT is I think you get a better analysis of communication with the pancreas duct and what the pancreas duct itself is doing. If you compare, there are some studies comparing MRIs to CTs, head-to-head for these, they're relatively equivalent. It doesn't show massive differences between the two, but anecdotally and personally, my strong preference is for an MRI if the patient can, is able to get one and is able to, doesn't mind being in a scanner for 45 minutes or however long they're in there. But that's my approach, but I just wanted to sort of parse it out with you guys a little bit. I think that's very reasonable. I mean, I think the guidelines, many of the guidelines say actual MRI and it's also institutionally based. So I think it's important. The one thing I'm gonna point out to you guys in the audience is that when you follow a guideline and there are three to choose from here and then there's the European guidelines, always document the reason for your surveillance interval. So if you're following the consensus guidelines, say as per consensus guidelines, we are repeating imaging in six months or as per ACG guidelines. The good news here is there was a meeting at DDW and there's a, very soon we're gonna have one merged guideline. So life will get easier for all of us. I don't know if it's very soon, but hopefully soon enough. But I just wanted to point that out. I think it's a point to know, we have a lot of folks in the community and not every community center has like a 256 CT scan. So sometimes if they're going out and they're getting a 64, like thick cut CT scan, that may be an emphasis that really, I'm gonna be like, no, you should come here, get your MRI, make sure that we can get a good look because the thicker the cuts, the more you're gonna miss small things. And so, and just to kind of echo what Ross, I think what you mentioned, and sometimes that gestalt, that movement speed is like, if you had a CT scan, sometimes I'd like to see the CT scan just to see what that change is, but know that there are variations in CT scanners or MRI capabilities at comparisons between institutions. So just be aware of what your institution has and what's out in the community before you order certain tests, not all MRIs or CT scans are the same. Yeah, that's a great point, Alex. And like a lot of institutions, like a lot of institutions around our facility use one and a half Tesla Magnet MRIs, and we have the benefit of a three Tesla MRI, which gives you just much crisper, higher definition images. And so it's your point of understanding your imaging capabilities and what you've got around you is a very, very good point. Pertinent question from the chat. When would it be reasonable for a general GI doc maybe out in the community with less sensitive imaging to follow these lesions versus sending them to a specialist or like a high-risk pancreas clinic? My take on that would be, you know, it's their comfort level. So, you know, if you're uncomfortable, it's not ever wrong to refer it out. I think understanding the nuances and what represents a high-risk lesion. And once they have any of those, that's a very important time to refer the patient because we should and could consider endoscopic ultrasound and multidisciplinary discussion. You know, we do our multidisciplinary tumor board discussions every week. We meet with the surgeons, the radiologists, the oncologists, radiation oncologists, radiologists. You know, it's a whole team of people and we review these high-risk cystic lesions all the time. And so we have the benefit of, you know, multidisciplinary discussion and trying to figure out, you know, what is going to be next, the best next step for this individual. And so, you know, we do have a lot of things that are resources at our disposal, but, you know, the long and short of it to me would be, you know, if you've got a low-risk appearing cyst, you probably should feel comfortable to follow that and monitor it over time. But if it's a lesion that's changing or developing high-risk features, that's a very good indication to refer. And if you don't have a process in place, like for follow-up, like you do for colon polyps and you're afraid you're going to lose track of the patient and surveillance, that's another reason. We oftentimes get patients referred. So, but I agree with Ross. Everything he said was spot on. I think we're going to get into this later, but I'm just curious, Dr. Shami and Dr. Bierlein, for, you know, an older patient like this, an 86-year-old that probably is not going to be a surgical candidate, when you talk about the risks and benefits of surveillance, are you bringing up cyst ablation, which I know you are thinking about starting to do relatively soon? It's funny you mentioned that. I actually do, I'll show you what, you know, imaging looks like on this patient coming up, but I did actually have that conversation with this specific patient. And we, you know, it's not for every patient and we can discuss that in more detail. I have some slides on it later if we get to it, but there are multiple different options for ablation. There's things like RFA, used to be ethanol. We now don't use ethanol with chemo ablations, but that is something we're starting at UVA is the chemo ablation. And, you know, they're for precancerous lesions for, so you cannot, you know, have, you have to think that there's no cancer truly in the lesion. And it comes with certain risks. And it's something that if you're going to be doing, I highly encourage you to talk to your surgeons, your oncologists, and make sure that, you know, again, it's being done in a team approach and that you're not just, you know, doing something without their knowing it, because there are risks to doing it. And not all of them are going to go according to plan. And you just need to be able to think about that, but it certainly can be considered in the right patient. So I'll keep rolling with this. So I just wanted to, this is a summary of, again, the imaging surveillance timing recommendations from the different guidelines. And you can see some of them, like the AGA, keep it pretty simple. They just say every year, as long as it's, you know, for an MRI for the, you know, first two years, and then you start to space it out. And if there are no changes after five years, then you can stop. This is a really controversial statement, and it's the only one of the guidelines that gives that recommendation. And then the other guidelines, you can read them, but they, you know, some say MRI or CT, some say MRI. The frequency at which you get the MRIs or CTs vary. Some say you alternate with the U.S. Some recommend a CA-19-9, whereas others don't even mention it. And so this is sort of an area where the guidelines are confusing. And to be honest with you, there's not really any great head-to-head data to say six months is better than 12 months. We do know that, you know, lesions that are high risk for developing or containing cancer are gonna be ones that change more frequently. And so, you know, and catching that earlier is better, but, you know, you're gonna survey a lot of cysts with this. And Ross, this table is beautiful, and I know one that you created. You know, the consensus guidelines and the ACG guidelines are very similar. The only difference is the interval with which to survey. So they all go based on size. If they don't have a high risk criteria, those two guidelines. And so they're very similar. You know, the AGA guidelines are an outlier in that you need two high risk features in order to do an EUS, but there are common themes to these guidelines. It's mostly size and surveillance interval. I'll show you that coming up in a second. So this is her MRI. So she did wanna do an MRI a year later, and lo and behold, her cyst has increased pretty significantly in size. It's gone from like 11 or 12 millimeters to about 25 millimeters, and there's now upstream dilation of the pancreas duct. So this is just a picture showing the upstream dilation of the pancreas duct from that one-year interval scan. And so now, what do you guys think here? I'm pretty worried about this. And so, you know, I told her, hey, we gotta do an EUS. Do you guys, anybody feel differently about that? No, absolutely. It's surprising, huh, how big it got and how the PD dilation? Yeah, it's pretty- It's kind of scary. Yeah, it's pretty scary. But for your surgeon too, I think sometimes, right? Like you had an aggressive surgeon. Some surgeons would understand, you know, that there's a chance that this is benign disease, but with that rapidity and change with that upstream dilation, I think some surgeons out there will take this out without an EUS. I think that's a minority. But- That's a good point, yeah. We actually did review it at our multidisciplinary, you know, conference. And because of her age, I think she's like 87 at this point, you know, they were like, please make sure that we're not dealing with something not, you know, that's totally benign. So, you know, when we think about what are indications for endoscopic ultrasound, the AGA is the only one that says you have to have two or more of the high-risk features here. So cysts that's three or greater centimeters, the presence of a dilated pancreas duct, which in general is thought to be five millimeters or greater, and the presence of a solid component. And you'll hear differences between a solid component and a mural nodule. Technically a solid component is solid tissue neighboring the cyst, and a mural nodule is like a solid growth within the wall of the cyst. It can be really hard to parse out the differences, particularly on cross-sectional imaging studies. It's much easier on EUS, but there are some nuances differences, but some of the guidelines mention mural nodules and solid components. Some just mentioned solid components, but just so you're aware of that. So again, some of the similarities you'll notice is the size. So they have a size cut-off of three centimeters. For all of these, the European guidelines really get to about four centimeters before they get too worried. They all have dilated pancreas duct, and they all talk about something about a solid component or a mural nodule. So again, there are some other ones, but these are the high-risk ones that uniformly, you should keep strongly in your brain about this, and there are the same amongst the guidelines. Similarly, when we think about indications for surgery, they all say if there's positive cytology or suspicious cytology, that's a strong indication in and of itself for surgery. The AGA is the only guideline that says you have to have both a solid component and a dilated pancreas duct if you don't have positive cytology. So if you don't have both a solid component and a dilated pancreas duct, the AGA guidelines do not recommend surgery. The other ones talk about either the presence of a mural nodule that's five millimeters or greater or a solid component. Pancreas duct dilation at 10 millimeters or bigger, as in two of the guidelines very clearly. So 10 millimeter or bigger pancreas duct, that's a high-risk lesion. I took her for EUS and sampled her cyst, the CEA was elevated, the amylase was elevated, and the cytology came back as mildly atypical ductal cells, and there was mucin seen here. So I did refer her to a surgeon to talk about what that would look like. And they did take her for a lateral pancreatectomy. The surgeon the other day was telling me that the patient was in the hospital for like three days and did fine and went home. It was one of the easiest recoveries of surgery he's had recently, which was funny because she's 87 years old. In her case, thankfully there was no malignancy and all lymph nodes were negative and it was consistent with a low-grade IPMN. But I thought this case was interesting and illustrative of a bunch of different points and following it and thinking about high-risk lesions and what they are, and when do we stop surveillance, and they're difficult decisions. That's a beautiful case. And I think it also matters if it's in the head, right? A Whipple would have been a little bit more difficult on her, but that's a beautiful illustration of a cyst going wrong. So thanks, Ross. Yeah, and that's a great point, Dr. Chamies, I think Whipple is a completely different beast. When you think about a Whipple, depending on where the Whipple, which hospital they're doing it, how high volume of a center, the mortality rates from a Whipple are somewhere between one and seven percent, sort of a common accepted number is like two to four percent. And then morbidity is relatively around 30 percent, but in some studies as high as 60 percent. And so it's a major operation. It's much, much different beast than a lateral or distal pancreatectomy, which usually involves a splenectomy due to blood supply. But if you're questioning if it's a Whipple, that's a completely different beast and a different conversation entirely. So when we think about branch duct IPMNs, again, one thing I want to point out is do not confuse these with main duct IPMNs. So main duct IPMNs have ductal dilation, and that duct is typically at least five to 10 millimeters. And those are different beasts. Those should go to surgery or multidisciplinary discussion very early. Up to 60 percent of those have high grade dysplasia or malignancy at the time of surgical resection. So those are different beasts. You'll separate those in your brain. When we think about branch duct IPMNs, we've talked about some of these high risk features. So I don't want to beat them into the ground here, and hopefully we can get to other cases. But, you know, just think about these high risk features that are listed here with the first three being the most important ones. Case four is a 37 year old lady who came in in January 2023 with some abdominal pain, and they got an image, and this is what it was when they sent it to me. It's about a three centimeter lesion in the body of the pancreas. So what are you guys thinking from a differential standpoint? I'll pull this back up. Really, it could be anything, right? There's, you know, the imaging isn't great. And, you know, again, it wasn't protocol to look for this. And it's just sort of, you know, a random looking lesion in the body of the pancreas. So given its size, what do you guys think you do here? She's young, right? 37. Yeah, and I sound like I'm age biased, but, you know, she has many more years to live. And I'm not sure I want to follow this. And the chance of it being an MCN is a little higher because those occur in women. So there are, I think, a few reasons that I would favor in EUS. I don't know what the rest of the panel feels. I would say the same thing. Maybe this is coming from someone who just took boards. But seeing a young woman with that solid looking cyst, it makes me just think of a solid pseudopapillary tumor. Not that it's definitely that, but it just, alarm bells are ringing when I see the young woman presenting with that type of looking cyst. Yeah, I thought the same thing. And even if it was a, you know, IPMN or MCN, you know, its size is already about three centimeters. And, you know, I just thought, she's young. Let's just answer this question definitively. So I brought her in and let me see if I can start this. So here's her image here. So you're seeing sort of a solid, maybe with a little bit of cystic components to it. And this is just the FNA of the lesion, trying to fan through to get different, to get, you know, different areas within the lesion. And this is, this was the results here. So it was a solid pseudopapillary neoplasm. You can see, that's what it looks like here. And they're called, you know, the aspirate, small cellular scant cells, loosely cohesive. And in this case, clinically, it seemed consistent with a pseudopapillary, solid pseudopapillary tumor. These are mixed solid and cystic lesions. And these are in young women, young being 20s to 30s in the vast majority of cases. And there's no connection to the pancreas duct. And in general, these need to be referred for surgery. Do you all have any other thoughts on these? No, it's a beautiful demonstration. You know, this one is a little bit more solid than one would classically see. And I think that's so important. I think doing the fine needle aspiration was key. Yeah, we'll get another one. So I got, this was a referral to me. Literally, the referral says 15 millimeter IPMN was the reason for referral. It's a 62 year old patient. And you can see the imaging here. When I looked at this imaging, you know, the thing that made me question exactly what this was, you can start to see a pretty significant peripheral rim enhancement of this. And so it just didn't sit with me well that this was necessarily an IPMN. But, you know, the radiologists were calling it an IPMN and I'm not a radiologist. And so, you know, I don't know, what else do you guys think about when you see this or what else do you think it could be? I don't think it's going to be an MCN. It's a male, right? Right. I mean, it doesn't look, again, SCNs also are more classically females and it doesn't really have that microcystic kind of look to it. I agree with you very well, it could be an IPMN. And then in terms of cystic neuroendocrine tumors, sometimes they can get that peripheral enhancement. So I guess that could also be on the differential. So I would favor C and D. Yeah. Was it a contrast, like a scan by chance? It was, yep. Was there any delayed enhancement of the lesion at all? I don't think there was delayed enhancement, no. Why do you ask that, Alex? Just sometimes with hypervascular lesions, you can get it more so in the delayed phase and that can be helpful in differentiating between say like I can enter like a more vascular like neuroendocrine tumor. So it's helpful when it's there, but when it's not, like just in this case, I think it's still, you know, if I think I saw it, I would do the same with Ross. You know, I think I'd favor an IPMN, but thickening or, you know, in the right milieu, I think it's an additional risk. So, you know, just for the sake of time, you know, I just didn't like the way it looked. And for me, I favored, you know, maybe this could be a neuroendocrine tumor. And so, you know, I typically wouldn't bring a 15 millimeter cyst in for an EUS, but just looking at it, just didn't sit right with me. So I did bring him in for an EUS. And on this, the things I want to point out are, you see how thick this wall is here. And so when I sampled it, you know, we talked a little bit earlier about sampling the wall of the cyst. And so you have to get really tangential with your needle and really try to get in the wall of it, because that's where the money's going to be in these, if it is a cystic neuroendocrine tumor. One caveat that I'll have too, is that I always have a little hesitation when I sample these. These are vascular lesions and their risk of post-sampling pancreatitis is real. And so thankfully I haven't had a nasty case yet of sampling one of these from pancreatitis, but definitely they're going to happen and I've seen them before. And it's just something to be aware of and to think about. Would you guys mind commenting on the role for like a contrast in ANSI-EUS for this case? I mean, I guess you could use it. I'm not sure that it's going to convince me not to biopsy the solid component. And so- I think that's the hardest part, right? You're not going to convince anybody to take this out just with a contrast with ANSI-EUS. Right, yeah. That's where, you know, it's like, well, yeah, we can look and see how vascular it is, but you're still, will it cause you to not sample these? And I think that's the real issue. I think the contrast in ANSI-EUS is it's not going to convince anybody not to do what they would otherwise. That's a good point, Alex. And I love the way that you kind of illustrate that you're going for the money, Ross. You're getting the solid component because that's really, really key because I'm not sure the fluid's going to give us much. Yeah, the fluid in these tends to not be very helpful. And I will say, this is a very cystic neuroendocrine tumor, not to be confused with non-cystic- Give us the answer. Yes, that's what it is. Here are some cells, and it stains positive for chromogranin. And it is a, they call it a low-grade epithelioid neoplasm, but in this case, it's a cystic neuroendocrine tumor. And so what do you do now? What do you guys, how do you all think about it? And what would you do next? So it's about 15 millimeter, 15 to 18 millimeter, depending on how you measure it, cystic neuroendocrine tumor in the body of the pancreas. And the patient's asymptomatic, right, Ross? Yeah, asymptomatic. I mean, usually when they're less than two centimeters, the chances of them metastasizing is really low. So one can argue to follow this. Again, if the patient's extraordinarily anxious, I guess you could convince the surgeon to remove it. But I think size means a lot in these cases. Yeah, exactly. That was our, we had a discussion at our tumor board and that was the same answer basically. And we spoke with the patient and had to meet the surgeons and ultimately we've elected to follow it radiographically for now. And once it hits that two centimeter mark, that could change, but it may never. And he's asymptomatic. So I tend to think about cystic neuroendocrine tumors with this priority, about cystic neuroendocrine tumors with this peripheral enhancement. They can have some delayed imaging, delayed enhancement like Dr. Podboy mentioned. On cytology, there tend to be these round, loosely cohesive cells. They'll stain positive for chromogranin. And just one thing to keep in the back of your mind when you see these is about 25% of them have an association with underlying MEN type one. And that's always fodder for boards. So just something to think about. Comments on these? No, it's beautifully illustrated. Just run through this one real quickly. We just got a couple of minutes left, but I'll be brief with this. So this is a 69 year old lady who had a history of hypertriglycerideemia induced pancreatitis. She was admitted three months prior to this and came in with significantly worsening abdominal pain. And this is her imaging. They call it 6.2 centimeter cystic lesion in the body of the pancreas that communicated with the duct. And upstream there was ductal communication. And as we talked about with her, because she was symptomatic, that's why I brought her in for EUS, thought this was most likely going to be a pseudocyst, but wanted to just quickly take a look at it and see what we were thinking this was going to be. Anybody else have any different thoughts on this besides EUS and sampling it and maybe draining it? No, because it's kind of unclear, right? Yeah, it's unclear. So I think sampling is very reasonable. So here is an MRI, here's her EUS. And here you can see this anechoic lesion, very simple appearing lesion. The wall is not super thick. I don't see septations. And so to me, this was a pseudocyst in this setting. And this is just me sampling it. And so I did sample it. It came back consistent with the pseudocyst. And this is just the drainage of it. This is put a wire in dilating the track here and with a four millimeter or six millimeter dilating balloon transgastric. And then here you can see the stent going in through the wall of the stomach and looping it in there. And then this is it down here. So because of this, this was associated with, ended up getting at, let's see here. She did well. This is her scan a month later. There's very clearly a disruption in the pancreas duct. So she had necrosis and developed a disconnected duct syndrome and had basically developed a fluid collection as a result of this. This part's a little controversial, but I'll plan to leave that double pigtail stent in forever. She will, if we were to remove that, in most cases, they're going to almost immediately recollect that fluid collection. And I don't think I've ever had a double pigtail stent out of one of these type of lesions migrate. It certainly can. Not the end of the world. If it does, the vast majority of them will pass on their own. And I see her yearly and she's done very well with no problems. So here we're just getting into some other information, which we can sort of stop unless anybody has any other points or you guys want to talk about anything in particular. There's two additional quick questions from the chat. So one, is there a risk of malignancy with SPN and NETs? And two, what is the role of a DOTATE scan for a neuroendocrine tumor? Do you routinely obtain it? Have you ever obtained one? I'll say for the DOTATE scan portion, you know, it's pretty rare to have a problem with a small neuroendocrine tumor of the pancreas. And so for that reason, we don't typically get them, but I think it's an important question to work with your local oncologist and your surgical oncologist or your hepatic pancreatic biliary surgeon to see what his or her practice is to see what his or her practice is and see how they, you know, like to follow things. But in general, I don't typically get a DOTATATE for, you know, these. Now, if we're talking about, you know, cystic or neuroendocrine tumors elsewhere, like multifocal in the duodenum or something that's a different question, but specifically of the pancreas in a small lesion, I tend not to. I don't know if you all have any other different thoughts. I agree completely, Ross. And I think with the malignancy potential for these is overall quite low, you know, assuming they're small. And once you get over two centimeters, that risk starts to rise. Once you get over three centimeters, that risk really starts to pick up. And that's sort of why they've moved to surgically excise these, you know, at that mark. Great. Rebecca, any other questions? All right. Well, I really want to thank the panelists. Ross, I mean, that was just completely outstanding. And I think you're the expert here, not me. And I do want to just sum up by saying, you know, thanks for attending. You know, pancreatic cysts are very, very common as we talked about. Eusthenosis are the ones we really want to follow. And as Ross really nicely showed us, you know, there are common features to the guidelines and that things to worry about, obviously positive cytology, dilated pancreatic duct, an associated mass, mural nodule, and obviously symptoms. And survey people if they are operative candidates and or are going to get systemic therapy. If they're not, then the question is, why do we really need to survey them? So with that, we really want to thank you. And I think the ASG has a few ending slides. All right. Thank you again to all our panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure you check out our upcoming educational events. Registration is open. The next Endo Hangout session, Negotiating Your First Job Contract, will take place on Thursday, June 8th, presented by Doug Adler from Porter-Evitts Hospital. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Thank you again for everyone for this excellent presentation. And thank you to the audience for making the session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Thank you.

pancreatic cysts

macrocystic mucinous cystic neoplasm

microcystic serous cystadenoma

diagnostic procedures

management

complications

accurate diagnosis

MCNs

CEA levels

amylase

glucose levels

surgical intervention