By Dr. Martin Lilian
TSO Expert Opinion provided by Dr. Martin Lilian
About Dr. Martin Lilian
Colorectal Surgery, General Surgery
Area Of Expertise
- Consultant-General & Laparoscopic Surgeon– Columbia Asia Hospital, Palam Vihar,Gurugram
- Consultant- General & Laparoscopic Surgeon – Artemis Hospital
- Dr. Lillian is amongst the best Surgeons in this part of the world, with tremendous experience of expertise gained at top hospitals.
- 09 years of Experience in all general and laparoscopic surgical procedures involving abdomen and pelvis, major intra-abdominal surgical procedures on liver, spleen, pancreas, and intestines.
- 5 years of experience as a Clinical Instructor in General Surgery at Mumbai University teaching interns, residents and medical students.
- MCI Certified – General Surgery.
- Laparoscopic intra-abdominal surgery training certificate from Asan Medical centre (ACT).
- Fellowship in Laparoscopic Surgery), Mumbai University: 2007-2009.
- Masters Degree in General Surgery (MS), Mumbai University: 2004-2007.
- Bachelors Degree in Medicine, (MBBS), GMC Nagpur: 1997-2003.
- Honors in Anatomy, Biochemistry, Physiology, Pathology, Pharmacology & General Surgery
- Best thesis in General Surgery, Department Of Surgery, LTIMMH & college, Mumbai University for 2007 on “A Study of intra-abdominal cysts and tumors”.
- Commendations by Nigeria Delta Corporation for humanitarian service to the people of On do State, Nigeria, 2011.
- Case Presentations During Scientific Conferences.
“Laparoscopic removal of intra-abdominal cysts: What Recent trials have to say”. Published in CSI Surgery Update 2009.
A case of a 62-year-old woman with an incidentally discovered pancreatic cyst
Thank you for allowing me to participate in your care. As a reminder, my opinion given below is completely independent from the opinion given to you by your doctors.
Summary of Patient Medical History
To be thorough, I wanted to start by summarizing the information that I have obtained by reviewing your records.
You are a 62-year-old female who has been generally healthy aside from high blood pressure and high cholesterol that are followed by your primary care doctor. Two months ago, you were involved in a motor vehicle accident and were taken to the emergency room. While there, you underwent a CT scan of the abdomen and pelvis to rule out trauma to your kidneys. This CT scan incidentally showed a small cyst in your pancreas, and you were asked to follow up with your primary care doctor who ordered an MRI/MRCP with contrast. The MRI/MRCP was read by a radiologist as showing a pancreatic cystic neoplasm measuring 2 cm. You have not had any upper abdominal pain, nausea, vomiting, diarrhea, jaundice, or weight loss. You have never had pancreatitis (inflammation of the pancreas). You have no family history of pancreatic cancer.
You subsequently saw a gastroenterologist who reviewed the case and recommended a follow up MRI/MRCP in one year to see if there had been any changes. You are concerned about waiting that long given the potential risk of developing cancer over time. You are seeking asecond opinion to see if there are any other options available.
Before proceeding further, I would like to discuss various types of pancreatic cystic neoplasms (PCNs). This information will help you better understand my thought process below. PCNs are divided into four types with variable potential to become malignant(cancerous) over time.
- Serous cystic tumors. These have little to no malignant potential.
- Mucinous cystic neoplasms. These are almost exclusive to women and do have malignant potential.
- Intraductal papillary mucinous neoplasms. These have malignant potential, especially if they affect the main duct of the pancreas.
- Solid pseudopapillary neoplasms. These have malignant potential.
Unfortunately, it is not always possible to tell exactly what kind of PCN you have from an MRI/MRCP. Without that information, we look for features that may be suspicious for cancer or developing cancer over time. These include the size of the cyst (though exactly what size is suspicious is up for debate), a solid portion to the cyst, enlargement of the
main duct of the pancreas, symptoms related to the cyst, and a family history of pancreatic cancer. Further testing is usually needed in these cases.
Now, on to Your Questions
1. Can you tell why I have a cyst on my pancreas?
As above, the MRI/MRCP confirms that your pancreatic cyst falls under the umbrella of a pancreatic cystic neoplasm. The MRI/MRCP cannot determine which exact type of pancreatic cystic neoplasm it is. The key question now is what to do about it. While avoiding cancer is a very important concern, we also want to avoid unnecessary testing and
2. What other tests do you think I need to do to make sure I don’t have cancer?
Reviewing your case, you do not have many of the suspicious features mentioned under background information. That said, depending on which expert opinion you obtain, the size of your cyst in and of itself may be enough to warrant further testing. Given that your cyst is over 1.5 cm in size, I would recommend that you undergo a test called EUS/FNA. EUS stands for endoscopic ultrasound, a procedure in which an ultrasound probe is placed down your esophagus and focused on the pancreas. At that point, a fine needle aspiration (FNA) of the pancreatic cyst can be performed. Various studies can be done on the fluid obtained from the cyst. These include tests called cytology, tumor marker analysis, and DNA analysis. The findings can help determine with more precision the exact type of PCN we are dealing with and the risk of the cyst becoming cancerous over time.
Based on the exact findings, recommendations could range from no follow up needed to repeating an MRI/MRCP in 6-12 months to proceeding with surgery.
3. Are there any specific symptoms that I need to watch for in my day-to-day life?
This is an excellent question. If you develop upper abdominal pain, nausea, vomiting, changes in bowel habits, jaundice, or weight loss, these should be reported to your doctor. If any of these symptoms are thought to result from the pancreatic cystic neoplasm, surgery could be recommended.
4. Are there any immediate treatment options that I should pursue at this time?
As above, I would proceed with the EUS/FNA. The findings will determine the proper treatment course.
5. Can you suggest any resources for me to look at?
Some trustworthy sites for patient information include the National Institutes of Health and the Mayo Clinic.
Summary of Recommendations
- Undergo a test called EUS/FNA to help determine the exact type of pancreatic cystic neoplasm and the risk of developing cancer over time.
- The next step after the EUS/FNA will depend on the exact findings. Recommendations could range from no follow up needed to repeating an MRI/MRCP in 6-12 months to proceeding with surgery.
- Keep an eye out for any symptoms such as upper abdominal pain, nausea, vomiting, changes in bowel habits, jaundice, or weight loss. These could potentially change the plan of action
Thank you for allowing me and the Try Second Opinion team to be part of your care. I hope I was able to answer your questions and that you find these recommendations helpful. I would be happy to answer any further questions that you may have.