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My name is Anne Marie Lennon.
I am an assistant professor of medicine here at Johns
Hopkins, and I am the director of the Pancreatic Cyst Clinic.
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The pancreas is at the top of your tummy, and in fact it sits on
top of your spine, so it's at the back, and it's divided into three portions.
The top of the pancreas is called the head, the middle of the pancreas is
called the body, and the end of the
pancreas is called the tail of the pancreas.
It has a tube running through it, which we call the main pancreatic duct.
And these have got little small tubes called branch ducts, which
bring one of the things that the pancreas makes pancreatic juice
into the main pancreatic duct, and then it flows into these
small bowel or the duodenum where is helps you digest your food.
Pancreatic cysts are like a balloon.
They're, it's filled with fluid, and it can occur
in the top or the head of the pancreas.
Or you can have a cyst in the body or in the tail.
In some people, you can have several cysts.
For example, you can have three or four cysts in the
tail, and sometimes you can get multiple cysts throughout the pancreas.
You can have a cyst in the tail, the body, and the head of the pancreas.
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We are seeing more and more people
with what we call incidentally found pancreatic cysts.
And what I mean by this, is they
went into a hospital for an entirely different reason.
For example, they had blood in their in their
urine and their doctors were worried about a kidney stone.
They had a scan, and they happened to find the pancreatic cyst.
And one of the reasons that this is, is occurring is
that people are getting more and more scans done more frequently.
So if you go into the emergency room for any cause, you often get a CAT scan.
The CAT scans and MRI scans are getting
better, and therefore picking up more pancreatic cysts.
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The first question we ask is when somebody comes to the
pancreatic cyst clinic is what type of cyst do they have?
And the reason that that's important to try and
work out what type of cyst that a patient
has is because it determines firstly what is their
management, and how do we look at the cyst.
And secondly what is the risk of it developing into a cancer.
The commonest type of cysts that you'll see in
the pancreas is a thing called a pancreatic pseudo-cyst.
And this occurs in people who have had pancreatitis.
It has no risk of ever developing into pancreatic cancer.
And usually just needs to be watched and often resolves by itself.
There are several other different types of cysts that you can get in the pancreas.
One type is called a Serous cyst this is common in
women, and has a very low risk of ever developing into cancer.
There's a third type of cyst which we call mucinous cyst, and this is because
the fluid inside the, the cyst is thick and gloopy or mucinous.
And these type of cysts are, have got a risk of developing into cancer.
So it's very important that we identify people
who have, who have these type of cysts.
And that we follow them, or if necessary,
remove the cyst to prevent somebody developing cancer.
One of the types of cysts that are precancerous are called an introductal
papillary mucinous neoplasm, or an IPMN for short.
There are three different types of IPMN's.
One type effects the main pancreatic duct, which
is the tube that runs through the pancreas.
And this has got a very high
risk of developing or changing into pancreatic cancer.
The risk in series is between up is between 50 to 70%.
And that's such a high risk that people who, in whom
we think may have a main duct IPMN should undergo surgery.
The second type of IPMN is called a branch duct IPMN.
And that's where one of the small side
branches gets larger and develops into a cyst.
This is also a precancerous type of cyst, but
the risk of it developing into cancer is much lower.
Series say that it's somewhere between 15 to 20%.
Thus, not all, a very small number of people
with these branch duct IPMN actually change or develop cancer.
But these types of cysts need to be followed so that we, if
a cyst is changed and we pick it up, and those people undergo surgery.
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There are several different tests that we can use to look at a pancreatic cyst.
We can use abdominal imaging for exa, for example
CT or MRI, and we can also use endoscopic ultrasound.
That's like an upper endoscopy.
It's where we put a small camera down into the stomach.
Which has an ultrasound probe on it, and the ultrasound waves pass through
the stomach and into the pancreas, and generate beautiful images of the pancreas.
This is probably the best test to look within the panc, within
the cyst to make sure that there's nothing changing within the cyst.
And it also allows us to put a tiny needle in, and take
a sample of the lining of the cyst, and also of the cyst fluid.
The best test that we currently have for differentiating what
type of cyst we're dealing with is called cyst fluid CEA.
It's good in that it has an accuracy of 78%, but it's not perfect.
One of the things that we need is we need better tests
to tell us firstly, what type of cyst are we dealing with.
Is this a type of cyst that has
a cancerous potential and needs to be followed?
Or is this a type of cyst which has a very low or
no cancerous potential, in which case it doesn't need to be followed as closely.
And secondly, what in those type of cysts which are precancerous, which
are the ones that are likely to change or develop into cancer.
This is something that we've been working on at Johns Hopkins.
Dr. Vogelstein and colleagues have recently published a paper which
showed that two genes are altered and mutated in people with IPMN.
But are not [INAUDIBLE] changed in people with cirrhosis.
And this, these tests appear to be of far higher
accuracy than what is currently available with cyst fluid CEA.
Now, I think that these are very exciting times.
We need to see if these tests are as good as we think they are.
But if they are, they may change, alter
the way in which we manage pancreatic cysts.
Branch duct IPMNs have a small but definite
risk of changing and developing into pancreatic cancer.
We know from studies done here at Johns Hopkins and elsewhere that
the time that it takes for the cyst to change is quite long.
Study by Dr. Ackerbusio here at Johns Hopkins showed that in
pancreas cancer, the cancer develops over many years, as approximately seven.
And therefore we have a long time to intervene
and remove a cyst before it develops into a cancer.
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One of the questions that patients always ask us is, when do you need to go surgery?
Now we have very good guidelines called the international
consensus criteria which tell us who should go to surgery.
If you're having some tips for example the cyst is
causing yellow jaundice or pancreatitis, then you need to consider surgery.
We also know that the cyst gets very
large, graze in three centimeters, the risk increases.
And again surgery should be considered.
Finally, it's important to look very carefully
within the cyst and with the imaging
test that we've discussed earlier to make
sure that there's nothing growing within the cyst.
Which is what we call a mural nodule or a solid component.
Because again that suggests that this is
maybe changing and surgery needs, should be considered.
These guidelines seem to be very safe and it, in people who don't fulfill
them the risk of there being a cancer within the cyst is very small.
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The pancreatic multidisciplinary program because so many people are being
diagnosed with pancreatic cysts consists of a group of pancreatic specialists.
There is myself.
I'm an interventional endoscopist.
We also have five dedicated pancreatic surgeons pancreatic pathologists,
as well as dedicated abdominal CT and MRI specialists.
We meet once a week to review all the cases of
the patients who are seen at the Pancreatic Cyst Clinic, and
then come up with a consensus as to what is the
cause of the cyst, and what our recommendations are for management.
And we're very happy to see people who are, have just been diagnosed with a cyst.
Or people who've had it for a while, or are looking for a second opinion.
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