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What Do These Following Lab Reports Indicate?
Question: Through CT I was recently diagnosed with a branch IPMN of the pancreas. I am a 36 year old single mother. I was told that the protocol is follow up MRI in one year. I am a psychiatric nurse practitioner and after reading the research am concerned by this approach. Specifically,
1. I have high anxiety. My quality of life is greatly impacted now. I am numb and unable to function waiting for this cyst to progress into cancer.
2. CT is not 100% for IPMN. Meaning I could have a benign psuedocyst?
3. Size is not always indicative of malignancy in IPMN. Per research branch IPMN has a risk of 3% malignancy and it usually takes 5 to 6 years to progress into malignancy if it is benign.
4. EUS is not 100%. The only sure thing is resection and hist. examination. Therefore I don't accept the algorithm of EUS every six months.
5. Prognosis - 5 year for non invasive is 80-100 after resection. Prognosis for benign resection excellent >95%. Why wait for malignancy to occur?
6. Will insurance pay for a resection if the lesion is 1cm? I do not have any mural findings but do have occasional upper left quadrant and back pain. My gastro originally thought this was GERD but now I'm wondering if it was the cyst?
Questions:
1. What is the likelihood that I currently have a cancerous lesion given that I have some symptoms but may also be GERD/anxiety related and a 1cm size cyst with no mural findings on CT?
2. What would your treatment plan recommendation be? I would like a EUS followed by immediate resection even if benign.
3. What are the risks of laparoscopic approach and would you also recommend taking the spleen and nodes? Since I have asthma I would like to keep my spleen for immunity purposes.
Any other helpful information or words of encouragement to ease my anxiety appreciated. Please do not be vague and say "consult with a gastro specializing in this" I already know that and have an appointment scheduled. I'm just looking for other opinions. Thank you.
1. I have high anxiety. My quality of life is greatly impacted now. I am numb and unable to function waiting for this cyst to progress into cancer.
2. CT is not 100% for IPMN. Meaning I could have a benign psuedocyst?
3. Size is not always indicative of malignancy in IPMN. Per research branch IPMN has a risk of 3% malignancy and it usually takes 5 to 6 years to progress into malignancy if it is benign.
4. EUS is not 100%. The only sure thing is resection and hist. examination. Therefore I don't accept the algorithm of EUS every six months.
5. Prognosis - 5 year for non invasive is 80-100 after resection. Prognosis for benign resection excellent >95%. Why wait for malignancy to occur?
6. Will insurance pay for a resection if the lesion is 1cm? I do not have any mural findings but do have occasional upper left quadrant and back pain. My gastro originally thought this was GERD but now I'm wondering if it was the cyst?
Questions:
1. What is the likelihood that I currently have a cancerous lesion given that I have some symptoms but may also be GERD/anxiety related and a 1cm size cyst with no mural findings on CT?
2. What would your treatment plan recommendation be? I would like a EUS followed by immediate resection even if benign.
3. What are the risks of laparoscopic approach and would you also recommend taking the spleen and nodes? Since I have asthma I would like to keep my spleen for immunity purposes.
Any other helpful information or words of encouragement to ease my anxiety appreciated. Please do not be vague and say "consult with a gastro specializing in this" I already know that and have an appointment scheduled. I'm just looking for other opinions. Thank you.
Brief Answer:
Details below.
Detailed Answer:
Hi Dear,
Firstly, thanks for choosing HealthcareMagic for your query.
I have gone through all your details and i appreciate your concern.
Just want to give you a briefing before answering your questions, so that you can understand things better.
You are suffering from a condition called Intraductal papillary mucinous neoplasm. This is a Benign condition. However, if left untreated SOME cases can become Malignant (Please pay special attention to word SOME).
Chances of IPMN transforming to malignant cancer is somewhat between 45-50%. However, if the tumor is resected in time, chances of it getting malignant are reduced to about 25-30%. Survival 5 years after resection of an IPMN without malignancy is approximately 85%(85% in text means approximately 90 to 95% in practical scenario). So frankly speaking things are not that bad as you are assuming (By reading the research).
Now let's come to your queries.
1) CT scan or USG alone can't help us differentiate between Malignant or benign lesion.So ask your Gastroenterologist to go for fine needle aspiration (FNAC) biopsy from the lesion to confirm the diagnosis. Fine needle aspiration biopsy will be performed through an endoscope at the time of endoscopic ultrasound, However, it can be performed through the skin using a needle guided by ultrasound or CT scanning. Expertise is required to perform this test. So please make sure that you have an experienced Gastro and Radioogist, well versed with this procedure.
This test will confirm whether 1 cm lesion is malignant or benign. Wait and watch, I don't feel is a good idea. When we have technology with us then why not to diagnose things at the earliest and take required action. Losing precious time waiting is not at all a good approach on part of your gastroenterologist.
Frankly speaking, we can't take chances, malignancy is possible in a cyst as small as 1mm and sometimes even large cysts are benign. So better to go for biopsy, things will be clear in 48 hours.
2) Treatment plan- Resect the cyst as soon as possible. Timely intervention reduces the risk of malignancy as explained above.
For me, I don't think watch and watch policy is good. Just resect the cyst out.
3) Laparoscopic procedures are latest and are minimally invasive as compared to conventional surgery. So chances of post-operative complications, infections are less and recovery is faster. However final verdict depends on the choice of surgeon.
Most important thing is that just make sure that laparoscopic surgery should be carried out by surgeons who are well experienced in performing pancreatic surgery. These procedures are not done by all Gastroenterologists or Surgeons.
Taking out spleen and nodes depends on results of biopsy. However whole body PET scan(positron emission tomography) can be done before going for laparoscopy to see any metastasis.PET will help us to decide whether to involve nodes and spleen or not.
General suggestion-
Be calm.
Don't panic.
Follow what I said.
Choose your Gastroenterologist carefully.
Go for timely intervention.
Have faith in God and keep yourself motivated.
85-90% cure rate is not that bad, so go for the investigations and let's keep our fingers crossed.
and please don't Google too much.
I hope I answered your query well and to the point. In case you need any further assistance I would be glad to help.
Remain motivated.
Good luck.
Thanks.
Details below.
Detailed Answer:
Hi Dear,
Firstly, thanks for choosing HealthcareMagic for your query.
I have gone through all your details and i appreciate your concern.
Just want to give you a briefing before answering your questions, so that you can understand things better.
You are suffering from a condition called Intraductal papillary mucinous neoplasm. This is a Benign condition. However, if left untreated SOME cases can become Malignant (Please pay special attention to word SOME).
Chances of IPMN transforming to malignant cancer is somewhat between 45-50%. However, if the tumor is resected in time, chances of it getting malignant are reduced to about 25-30%. Survival 5 years after resection of an IPMN without malignancy is approximately 85%(85% in text means approximately 90 to 95% in practical scenario). So frankly speaking things are not that bad as you are assuming (By reading the research).
Now let's come to your queries.
1) CT scan or USG alone can't help us differentiate between Malignant or benign lesion.So ask your Gastroenterologist to go for fine needle aspiration (FNAC) biopsy from the lesion to confirm the diagnosis. Fine needle aspiration biopsy will be performed through an endoscope at the time of endoscopic ultrasound, However, it can be performed through the skin using a needle guided by ultrasound or CT scanning. Expertise is required to perform this test. So please make sure that you have an experienced Gastro and Radioogist, well versed with this procedure.
This test will confirm whether 1 cm lesion is malignant or benign. Wait and watch, I don't feel is a good idea. When we have technology with us then why not to diagnose things at the earliest and take required action. Losing precious time waiting is not at all a good approach on part of your gastroenterologist.
Frankly speaking, we can't take chances, malignancy is possible in a cyst as small as 1mm and sometimes even large cysts are benign. So better to go for biopsy, things will be clear in 48 hours.
2) Treatment plan- Resect the cyst as soon as possible. Timely intervention reduces the risk of malignancy as explained above.
For me, I don't think watch and watch policy is good. Just resect the cyst out.
3) Laparoscopic procedures are latest and are minimally invasive as compared to conventional surgery. So chances of post-operative complications, infections are less and recovery is faster. However final verdict depends on the choice of surgeon.
Most important thing is that just make sure that laparoscopic surgery should be carried out by surgeons who are well experienced in performing pancreatic surgery. These procedures are not done by all Gastroenterologists or Surgeons.
Taking out spleen and nodes depends on results of biopsy. However whole body PET scan(positron emission tomography) can be done before going for laparoscopy to see any metastasis.PET will help us to decide whether to involve nodes and spleen or not.
General suggestion-
Be calm.
Don't panic.
Follow what I said.
Choose your Gastroenterologist carefully.
Go for timely intervention.
Have faith in God and keep yourself motivated.
85-90% cure rate is not that bad, so go for the investigations and let's keep our fingers crossed.
and please don't Google too much.
I hope I answered your query well and to the point. In case you need any further assistance I would be glad to help.
Remain motivated.
Good luck.
Thanks.
Above answer was peer-reviewed by :
Dr. Arnab Banerjee
Thank you for your detailed follow up. Can you please clarify when you said 25% chance of malingnancy AFTER resection? Where does this come from (for example the person gets a new IPNM or the excision wasn't complete?) and what are the risk factors (age, gender, etc.)?
Brief Answer:
follow up query.
Detailed Answer:
Hi Dear,
Even after resecting the cyst,In few cases it reappears again.Out of those few cases around 25% can get malignant if not resected again.
Cyst consists of a number of units called cells.Cells are the smallest unit of our body and can be seen under electron microscope only.Even after resecting any cyst(Not just IPNM) there are few defective cells which are left there.Sometimes(No one can predict) in some patients these defective cells again proliferate causing recurrence of cyst.
There are no predefined risk factor.Frankly speaking it's just a matter of chance.No one can predict it.
Please attach report of your CT i want to go through it.
Waiting.
Thanks.
I hope i cleared your doubts well,In case you have further questions regarding IPNM feel free to ask.
follow up query.
Detailed Answer:
Hi Dear,
Even after resecting the cyst,In few cases it reappears again.Out of those few cases around 25% can get malignant if not resected again.
Cyst consists of a number of units called cells.Cells are the smallest unit of our body and can be seen under electron microscope only.Even after resecting any cyst(Not just IPNM) there are few defective cells which are left there.Sometimes(No one can predict) in some patients these defective cells again proliferate causing recurrence of cyst.
There are no predefined risk factor.Frankly speaking it's just a matter of chance.No one can predict it.
Please attach report of your CT i want to go through it.
Waiting.
Thanks.
I hope i cleared your doubts well,In case you have further questions regarding IPNM feel free to ask.
Above answer was peer-reviewed by :
Dr. Yogesh D
Dr.
I attached my ultrasound results as CT report is still not available. I realize you can't extract much useful information out of this but I'm hoping this is suggestive the cyst is in the tail as I understand surgery options and outcomes are a lot better/easier when it is in this location as opposed to the head or body? Will upload CT as soon as it becomes available.
I attached my ultrasound results as CT report is still not available. I realize you can't extract much useful information out of this but I'm hoping this is suggestive the cyst is in the tail as I understand surgery options and outcomes are a lot better/easier when it is in this location as opposed to the head or body? Will upload CT as soon as it becomes available.
Brief Answer:
Follow up answer.
Detailed Answer:
Hi again dear,
Sorry for a bit late reply,
Have gone through your report.As clearly stated in report window was not at all good and pancreas can't be localised clearly.
But as tail end is comparatively hypoechoic most likely cyst is at tail end.Prognosis and ease to operate is much easy near the tail end then head end of pancreas.
Pancreatic juices,Hormones etc are mostly secrered by acinar cells in head body,So if given a choice best part to have cyst is tail.
Waiting for CT reports.
Regards.
Follow up answer.
Detailed Answer:
Hi again dear,
Sorry for a bit late reply,
Have gone through your report.As clearly stated in report window was not at all good and pancreas can't be localised clearly.
But as tail end is comparatively hypoechoic most likely cyst is at tail end.Prognosis and ease to operate is much easy near the tail end then head end of pancreas.
Pancreatic juices,Hormones etc are mostly secrered by acinar cells in head body,So if given a choice best part to have cyst is tail.
Waiting for CT reports.
Regards.
Above answer was peer-reviewed by :
Dr. Yogesh D
I just uploaded the CT. 1.0x0.7 cm hypodense lesion in the tail no ductal dilation.
Brief Answer:
Upload high resolution photos of CT film.
Detailed Answer:
Hi again,
A cyst is a sac that may be filled with air, fluid or other material,therefore appear as hypoechoic.Magnetic resonance cholangiopancreatography is a special type of magnetic resonance imaging exam that produces detailed images of the pancreatic systems.In patient in which CT is not conclusive,MRCP is done if it shows an increase in signal intensity of the lesion and its communication with the ductal system,then lesion is classified as the cystic lesion as a main duct in intraductal papillary mucinous neoplasm.
Please upload claer high resolution films of CT scan.I want to see them(Not report Fils of CT).
Waiting.
Upload high resolution photos of CT film.
Detailed Answer:
Hi again,
A cyst is a sac that may be filled with air, fluid or other material,therefore appear as hypoechoic.Magnetic resonance cholangiopancreatography is a special type of magnetic resonance imaging exam that produces detailed images of the pancreatic systems.In patient in which CT is not conclusive,MRCP is done if it shows an increase in signal intensity of the lesion and its communication with the ductal system,then lesion is classified as the cystic lesion as a main duct in intraductal papillary mucinous neoplasm.
Please upload claer high resolution films of CT scan.I want to see them(Not report Fils of CT).
Waiting.
Above answer was peer-reviewed by :
Dr. Raju A.T
I'm sorry I thought earlier you asked for a "report" not the images. I have ordered them and not sure how long it will take to obtain.
Regarding your comment on main duct. I have a question. The radiologist advised me in person that this was a fluid filled side branch IPMN. It is my understanding that side branch IPMNs have much lower rates of malignancy as opposed to "main duct". Your reply concerns me because it seems like you are saying I could possibly have a main duct IPMN when the report clearly states side branch. Can you clarify your answer? Thanks in advance.
Regarding your comment on main duct. I have a question. The radiologist advised me in person that this was a fluid filled side branch IPMN. It is my understanding that side branch IPMNs have much lower rates of malignancy as opposed to "main duct". Your reply concerns me because it seems like you are saying I could possibly have a main duct IPMN when the report clearly states side branch. Can you clarify your answer? Thanks in advance.
Brief Answer:
Follow up answer.
Detailed Answer:
Hi,
Sorry for a bit late reply.
Firstly just a briefing about what is MRCP and why do we need to do it even after CT scan.
This description is given in a very easy language so that you can easily understand things,I am not using technical terms.
Magnetic resonance cholangiopancreatography is a special type of magnetic resonance imaging.
Principle of MRI is that it breaks water in tissue.A normal tissue has normal supply of blood(which contains water),When ever there is a cancerous growth the number of cells increases in that particular tissie hence indirectly it needs more blood supply(more water) So when MRI is done the tissue or cell having cancerous growth will show more water contents then normal tissue or cell.
Principle of CT scan-X rays are given along 360 degrees and multiple images are taken.
So MRI is far superior then CT to see a cyst and its extensions.
Therefore although CT scan shows that cyst is not in main duct MRCP is adviced.
For that reason only i want to see your films and want you to go for MRCP.
CT is suggestive not diagnostic.
Regards.
Follow up answer.
Detailed Answer:
Hi,
Sorry for a bit late reply.
Firstly just a briefing about what is MRCP and why do we need to do it even after CT scan.
This description is given in a very easy language so that you can easily understand things,I am not using technical terms.
Magnetic resonance cholangiopancreatography is a special type of magnetic resonance imaging.
Principle of MRI is that it breaks water in tissue.A normal tissue has normal supply of blood(which contains water),When ever there is a cancerous growth the number of cells increases in that particular tissie hence indirectly it needs more blood supply(more water) So when MRI is done the tissue or cell having cancerous growth will show more water contents then normal tissue or cell.
Principle of CT scan-X rays are given along 360 degrees and multiple images are taken.
So MRI is far superior then CT to see a cyst and its extensions.
Therefore although CT scan shows that cyst is not in main duct MRCP is adviced.
For that reason only i want to see your films and want you to go for MRCP.
CT is suggestive not diagnostic.
Regards.
Above answer was peer-reviewed by :
Dr. Remy Koshy
Six CT images have been uploaded this is the best size and resolution I could get. Thank you sir.
Brief Answer:
Follow up answer.
Detailed Answer:
Hi again,
Have gone through scans.
Good news is that images are good and main duct is not involved and most likely MRCP is going to show the same results most likely.
Prognosis post resection of side branch IPMN is very good and far better then main Duct IPMN.
Please ask any question If you have now regarding scn images etc.
Thanks.
Follow up answer.
Detailed Answer:
Hi again,
Have gone through scans.
Good news is that images are good and main duct is not involved and most likely MRCP is going to show the same results most likely.
Prognosis post resection of side branch IPMN is very good and far better then main Duct IPMN.
Please ask any question If you have now regarding scn images etc.
Thanks.
Note: For further follow up on digestive issues share your reports here and Click here.
Above answer was peer-reviewed by :
Dr. Remy Koshy
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