Lesiones Quísticas de Páncreas ¿Hay Malignidad?

Presentación del tema: "Lesiones Quísticas de Páncreas ¿Hay Malignidad?"— Transcripción de la presentación:

1 Lesiones Quísticas de Páncreas ¿Hay Malignidad?
Dra. Carmen Villalba Martín Imagen Abdominal Complejo Hospitalalario Universitario de Santiago de Compostela

2 ¡¿Es la lesión benigna o es maligna?!
Se detecta una masa quística en el páncreas ¡¿Es la lesión benigna o es maligna?! When we perform US, CT or MRI we detect an adrenal mass frequently, the so called incidentaloma. What to do in such occasions? CARACTERIZACIÓN de la LESIÓN

3 CLASIFICACIÓN MULTITUD DE POSIBILIDADES...
The conclusions regarding to the role of imaging in functional adrenal lesions are that imaging allows precise location and extension of the lesions, providing accurate depiction of the adrenal morphology, and thus, allowing diferential diagnosis between adrenal tumor or adrenal hyperplasia. Imaging also lets us to exclude contralateral tumors. Several features may suggest a benign or malignant nature of the tumors. CT is the imaging modality of choice because of its better spatial resolution, and more widely avalable and also chiper than MRI, although MR may be useful in certain circumstances, because of its better tisue characterization capabilities, and finally, adrenal vein sampling is recommended for evaluation of primary aldosteronism in patients with equivocal CT or MR findings. Ros PR, Cystic masses of the pancreas. Radiographics 1992; 12:

4 PANDEMIA de MASAS QUISTICAS PANCREATICAS
QUISTES PANCREATICOS INCIDENTALES (1/3 de las Masas Quísticas Pancreáticas)

5 Necesitamos adquirir un conocimiento: ser Expertos
Ese CONOCIMIENTO consiste en reconocer determinados patrones radiológicos y sintetizarlos en una matriz mental coherente, organizada y manejable... Las reglas clásicas ... ¿son suficientes? This is the case of a fifty-year-old woman admited for a well established Cushing syndrome. Biochemical background suggested an extradrenal tumor producing ectopic ACTH. A whole body enhanced CT scan was performed looking for a nonendocrine tumor, but the only pathologic finding was a round, 3-cm, left adrenal tumor which has central low attenuation. Note the hyperplasia of the contralateral adrenal, in contrast with the atrophic contralateral adrenal usually associated with a functional adrenal tumor causing Cushing syndrome.

6 NO PANCREATITIS, NO PSEUDOQUISTE...
REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS NO PANCREATITIS, NO PSEUDOQUISTE... … NO SIEMPRE!! PACIENTES CON PANCREATITIS AGUDA PUEDEN NO HABER MOSTRADO SINTOMAS CLINICOS ESPECIFICOS... O NO HABER SIDO DIAGNOSTICADOS

7 PANCREATITIS, ENTONCES... PSEUDOQUISTE
REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS PANCREATITIS, ENTONCES... PSEUDOQUISTE DIAGNOSTICAR UNA NEOPLASIA COMO PSEUDOQUISTE NO ES INFRECUENTE 2. ANALICEMOS CADA LESION!!

8 CUIDADO CON EL FENOMENO DEL “PRIMER HALLAZGO”
REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS CUIDADO CON EL FENOMENO DEL “PRIMER HALLAZGO” PANCREATITIS + PSEUDOQUISTE + PANCREAS DIVISUM + TUMOR MICROQUISTICO SEROSO

9 PLANTEAMIENTO DIAGNOSTICO
REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS PLANTEAMIENTO DIAGNOSTICO 1- Establecer el diagnostico diferencial entre PSEUDOQUISTE y TUMOR QUISTICO 2- Definir correctamente el TIPO HISTOLOGICO de un TUMOR QUISTICO

10 UN DATO TRANQUILIZADOR:
REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS UN DATO TRANQUILIZADOR: PSEUDOQUISTES  90% NEOPLASIAS QUISTICAS  10% (1% de los CANCERES PANCREATICOS) DILEMA DIAGNÓSTICO Establecer el diagnostico diferencial entre PSEUDOQUISTE y TUMOR QUISTICO

11 NEOPLASIAS QUISTICAS (90%) (10%)
QUISTES VERDADEROS (SEROSOS Y MUCINOSOS) -Cistadenoma Seroso -Tumor Mucinoso DILATACION DUCTAL -IPMNs - This is the case of a fifty-year-old woman admited for a well established Cushing syndrome. Biochemical background suggested an extradrenal tumor producing ectopic ACTH. A whole body enhanced CT scan was performed looking for a nonendocrine tumor, but the only pathologic finding was a round, 3-cm, left adrenal tumor which has central low attenuation. Note the hyperplasia of the contralateral adrenal, in contrast with the atrophic contralateral adrenal usually associated with a functional adrenal tumor causing Cushing syndrome. (10%) DEGENERACION QUISTICA TUMORAL

12 NEOPLASIA EPITELIAL SOLIDO PAPILAR ADENOCARCINOMA DUCTAL
No siempre es fácil... NEOPLASIA EPITELIAL SOLIDO PAPILAR TUMOR NEUROENDOCRINO Insulinoma. Secuencia Turbo espín eco T2 ADENOCARCINOMA DUCTAL ABSCESO TBC

13 Sahani, D. V. et al. Radiographics 2005; 25: 1471-1484
REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS PATRONES CLÁSICOS Althoug the low attenuation of basal ganglia and periventricular white matter resolved in 24 hours, thus related to edema secondary to acute hypertensive encephalopathy, a cerebral infarct at the level of the left internal capsula can be noted. Before the pheochromocitoma could be removed, a hemorrhage in the right internal capsula was developed. Sahani, D. V. et al. Radiographics 2005; 25:

14 Pequeños Quistes Uniloculares
Neoplasia quística mucinosa Neoplasia mucinosa papilar intraductal de una colateral Cistadenoma seroso Neoplasias quísticas de tumores de los islotes Adenocarcinoma ductal Neoplasia sólida seudopapilar de páncreas Associated with von Hippel-Lindau disease, polycystic kidney disease, and cystic fibrosis Quistes verdaderos Quiste linfoepitelial Handrich SJ et al. The natural history of the incidentally discovered small simple pancreatic cyst: Long-term follow-up and clinical implications AJR, 2005; 184: 20-23

15 Pequeños Quistes Uniloculares
Tuberculosis pancreática y suprarrenal

16 PATRON MICROQUISTICO - FOCAL
Adrenal hyperplasia occurs in 70% of patients with Cushing’s disease, and may result in difuse thickening of adrenal glands, but retention of the normal shape. This enlargement is usually smooth. SIN PROBLEMA... CISTADENOMA SEROSO!!

17 PATRÓN FOCAL: ¿SÓLO ADENOMA SEROSO MICROQUISTICO?
Adrenal hyperplasia occurs in 70% of patients with Cushing’s disease, and may result in difuse thickening of adrenal glands, but retention of the normal shape. This enlargement is usually smooth. IPMN PANCREATITIS CRONICA QUISTE POSTRAUMATICO

18 PATRON MICROQUISTICO - FOCAL
Serous cystadenoma Mucinous cystic neoplasm Metastases Lymphoma Ductal adenocarcinoma Pancreatitis Intraductal papillary mucinous neoplasm Sarcoma Adrenal hyperplasia occurs in 70% of patients with Cushing’s disease, and may result in difuse thickening of adrenal glands, but retention of the normal shape. This enlargement is usually smooth. Hsu-Chong Y et al. Microcystic features at US: A nonspecific sign for microcystic adenoma of the Pancreas. Radiographics, 2001; 21:

19 PATRON MICROQUISTICO - DIFUSO
Cistadenoma Seroso Insulinoma. Secuencia Turbo espín eco T2 Von-Hippel-Lindau Pancreatititis Crónica

20 PATRON MICROQUISTICO - DIFUSO
Neolplasia quística mucinosa Neoplasia mucinosa papilar intraductal Cistadenoma seroso Adenocarcinoma ductal Asociado a enfermedad de von Hippel-Lindau, enfermedad renal poliquística y a Fibrosis quística Pancreatitis Adrenal hyperplasia occurs in 70% of patients with Cushing’s disease, and may result in difuse thickening of adrenal glands, but retention of the normal shape. This enlargement is usually smooth. Hsu-Chong Y et al. Microcystic features at US: A nonspecific sign for microcystic adenoma of the Pancreas Radiographics, 2001; 21:

21 MACROQUISTICO UNILOCULAR
Cushing syndrome is defined as increased glucocorticoid levels from any cause, and may be divided into ACTH- dependent and ACTH-independent forms. Adrenal glands are often symetrically enlarged in patients with ACTH-dependent Cushing syndrome; however up to 30% of patients will have normal-size adrenal glands. The more frequent cause of Cushing syndrome is the Cushing disease, where a pituitary adenoma or hyperplasia secret excess ACTH, which represents the 80% of Cushing syndrome. Cushing syndrome is being reported with increasing frequency in association with the autonomous production of ACTH or CHR-like by nonendocrine tumors, with the resultant development of adrenal hyperplasia. The mayority of these cases have been associated with oat-cell bronchogenic carcinoma, bronchial adenomas, carcinoid tumor, ovaric and pancreatic tumors, timoma, medullary thiroid carcinoma, pheochromocytoma and adrenal carcinoma) The Hallmark in these cases of ectopic ACTH is hipokaliemic alcalosis, and also edema and hypertension are more common in these patients than in Cushing’s syndrome from other causes and are attributed to extremely high levels of cortisol secretion. Cushing’s syndrome ACTH-independent is due to a primary adrenal neoplasm, usually a benign adenoma and represents the 15-25% of Cushing’s syndrome. CISTADENOCARCINOMA MUCINOSO CISTADENOMA MACROQuístico SEROSO

22 MACROQUISTICO UNILOCULAR
Cushing syndrome is defined as increased glucocorticoid levels from any cause, and may be divided into ACTH- dependent and ACTH-independent forms. Adrenal glands are often symetrically enlarged in patients with ACTH-dependent Cushing syndrome; however up to 30% of patients will have normal-size adrenal glands. The more frequent cause of Cushing syndrome is the Cushing disease, where a pituitary adenoma or hyperplasia secret excess ACTH, which represents the 80% of Cushing syndrome. Cushing syndrome is being reported with increasing frequency in association with the autonomous production of ACTH or CHR-like by nonendocrine tumors, with the resultant development of adrenal hyperplasia. The mayority of these cases have been associated with oat-cell bronchogenic carcinoma, bronchial adenomas, carcinoid tumor, ovaric and pancreatic tumors, timoma, medullary thiroid carcinoma, pheochromocytoma and adrenal carcinoma) The Hallmark in these cases of ectopic ACTH is hipokaliemic alcalosis, and also edema and hypertension are more common in these patients than in Cushing’s syndrome from other causes and are attributed to extremely high levels of cortisol secretion. Cushing’s syndrome ACTH-independent is due to a primary adrenal neoplasm, usually a benign adenoma and represents the 15-25% of Cushing’s syndrome. ADENOCARCINOMA PANCREATITIS AGUDA + DEBRIS

23 MACROQUISTICO UNILOCULAR
El PATRON MACROQUISTICO UNILOCULAR ES ABSOLUTAMENTE INESPECIFICO Cushing syndrome is defined as increased glucocorticoid levels from any cause, and may be divided into ACTH- dependent and ACTH-independent forms. Adrenal glands are often symetrically enlarged in patients with ACTH-dependent Cushing syndrome; however up to 30% of patients will have normal-size adrenal glands. The more frequent cause of Cushing syndrome is the Cushing disease, where a pituitary adenoma or hyperplasia secret excess ACTH, which represents the 80% of Cushing syndrome. Cushing syndrome is being reported with increasing frequency in association with the autonomous production of ACTH or CHR-like by nonendocrine tumors, with the resultant development of adrenal hyperplasia. The mayority of these cases have been associated with oat-cell bronchogenic carcinoma, bronchial adenomas, carcinoid tumor, ovaric and pancreatic tumors, timoma, medullary thiroid carcinoma, pheochromocytoma and adrenal carcinoma) The Hallmark in these cases of ectopic ACTH is hipokaliemic alcalosis, and also edema and hypertension are more common in these patients than in Cushing’s syndrome from other causes and are attributed to extremely high levels of cortisol secretion. Cushing’s syndrome ACTH-independent is due to a primary adrenal neoplasm, usually a benign adenoma and represents the 15-25% of Cushing’s syndrome. Procacci C et al. Characterization of Cystic tumors of the pancreas: CT accuracy JCAT, (6):

24 CASI CUALQUIER NEOPLASIA PANCREATICA PUEDE PRESENTARSE COMO UNA MASA QUISTICA
Insulinoma. Secuencia Turbo espín eco T2

25 ¿SON NUESTROS PATRONES CLASICOS
No siempre es fácil... ¿SON NUESTROS PATRONES CLASICOS UTILES? ¿Cuál es la Cuestión?

26 MASAS QUÍSTICAS PANCREÁTICAS: ¡¡CONOCE TUS LIMITACIONES!!
60%  podrían ser caracterizadas 25%  hallazgos inespecíficos 15%  hallazgos que llevan a un diagnóstico incorrecto Insulinoma. Secuencia Turbo espín eco T2 Procacci C et al. Characterization of Cystic tumors of the pancreas: CT accuracy JCAT, (6):

27 LA MEJOR MANERA DE APRENDER CONSISTE EN DESAPRENDER
LAS REGLAS CLASICAS SOBRE MASAS QUISTICAS PANCREATICAS LA MEJOR MANERA DE APRENDER CONSISTE EN DESAPRENDER (Eduardo Punset)

28 RADIÓLOGO EXPERTO -Alta EFICIENCIA VISUAL (detectar las anomalías importantes) -Rápidamente selecciona un ESQUEMA MENTAL DIAGNOSTICO This is the case of a fifty-year-old woman admited for a well established Cushing syndrome. Biochemical background suggested an extradrenal tumor producing ectopic ACTH. A whole body enhanced CT scan was performed looking for a nonendocrine tumor, but the only pathologic finding was a round, 3-cm, left adrenal tumor which has central low attenuation. Note the hyperplasia of the contralateral adrenal, in contrast with the atrophic contralateral adrenal usually associated with a functional adrenal tumor causing Cushing syndrome. Wood BP. Visual expertise Radiology, 1999; 211: 1-3

29 EVALUACIÓN DEL EXPERTO
1- EDAD y SEXO 2- ENFERMEDADES ASOCIADAS 3- SINTOMAS 4- TAMAÑO 5- LOCALIZACION 6- CALCIFICACION 7- CONTENIDO DEL QUISTE 8- COMUNICACION CON EL CONDUCTO PPAL 9- PARED, SEPTOS Y NODULOS 10- REALCE TRAS LA ADMINISTRACIÓN DE CTE 11- METASTASIS

30 EDAD Courtesy Prof. Curry Insulinoma. Secuencia Turbo espín eco T2
CISTADENOMA SEROSO 74 años PANCREATOBLASTOMA 13 años

31 EDAD y SEXO Pancreatoblastoma  Neoplasia pancreática más frecuente en NIÑOS. Neoplasia epitelial sólida y papilar del páncreas  tumor infrecuente con potencial maligno intermedio, que afecta a MUJERES JÓVENES. Tumor macroquístico mucinoso Neoplasia con alto potencial maligno, que afecta a MUJERES de MEDIANA EDAD en cuyas paredes existe estroma de tipo ovárico. Cistadenoma seroso microquístico, típicamente afecta a MUJERES MAYORES de 60 años. Insulinoma. Secuencia Turbo espín eco T2

32 ENFERMEDADES ASOCIADAS
La mayoría de los quistes congénitos de páncreas se asocian con enfermedades genéticas incluyendo: -Von Hippel-Lindau -Fibrosis Quística -Enf. Poliquística Renal del Adulto Insulinoma. Secuencia Turbo espín eco T2

33 ENFERMEDADES ASOCIADAS
Insulinoma. Secuencia Turbo espín eco T2 FIBROSIS QUISTICA VON HIPPEL-LINDAU

34 PUEDEN DECIDIR LA ACTITUD TERAPEUTICA
SINTOMAS PUEDEN DECIDIR LA ACTITUD TERAPEUTICA Insulinoma. Secuencia Turbo espín eco T2

35 QUISTES UNILOCULARES < 3cms
TAMAÑO MENOS del 5% de los QUISTES PANCREATICOS DETECTADOS INCIDENTALMENTE < 2 cm SON MALIGNOS QUISTES UNILOCULARES < 3cms CASI SIEMPRE BENIGNOS Insulinoma. Secuencia Turbo espín eco T2 Fernández-del Castillo C et al. Incidental Pancreatic Cysts. Arch Surg 2003, vol. 138: Sahani DV et al. Small ( 3-cm) pancreatic cysts: how aggressive should we be? Radiology (in press)

36 CONTENIDO DEL QUISTE El contenido del quiste puede mostrar características específicas. MUCINA producida por tumores puede presentar hiperseñal tanto en secuencias potenciadas en T1 y T2. Material Hemorrágico o proteináceo puede mostrar la misma intensidad dde señal. Insulinoma. Secuencia Turbo espín eco T2