Pancreatic cystic neoplasms encompass broad range of different lesions, including intraductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms (MCNs), serous cystadenomas (SCAs), cystic neuroendocrine tumors (NETs), and variety of additional lesions
Lesions are increasingly being incidentally identified on imaging exams (CT and MR) as imaging technology has improved
Incidence increases with age and may be up to 25% in patients > 70 years of age
No clear consensus on optimal management of these lesions, which requires balance between avoiding overtreatment (as most of these are ultimately benign) and appropriate surveillance/treatment of lesions with greater risk of malignancy
Avoiding unnecessary surgery is important, as surgical mortality during pancreatic resection is 1-7% and morbidity as high as 64%
Pancreatic cysts are extremely common (reported prevalence: 2-38%) with any given cyst estimated to carry frank malignancy in only 0.01% of cases, further emphasizing need to appropriately risk stratify these lesions
Field defect: IPMN may be marker of background parenchymal abnormality indicative of increased risk of invasive pancreatic cancer at other sites within pancreas
Pancreatic Cyst Management Algorithms
5 most commonly utilized management systems include International Association of Pancreatology (IAP) in 2017, American Gastroenterological Association (AGA) in 2015, European Study Group on Cystic Tumors of the Pancreas in 2018, American College of Gastroenterology (ACG) guidelines in 2018, and American College of Radiology (ACR) guidelines in 2017
ACR released management system for pancreatic cysts in 2017, although this system is less commonly utilized in clinical practice (particularly at high-volume pancreatic surgery centers)
Each system has different approaches to pancreatic cysts in terms of type of cysts dealt with, manner of surveillance, and manner of initial evaluation
IMAGING ANATOMY
Most Common Pancreatic Cystic Lesions
Growing Role of EUS
CLINICAL IMPLICATIONS
IAP Guidelines (2017)
AGA Guidelines (2015)
American College of Gastroenterology (ACG) Guidelines (2018)
European Study Group on Cystic Tumors of the Pancreas Guidelines (2018)
ACR White Paper on Incidental Pancreatic Cysts (2017)
Data Comparing Different Cyst Management Algorithms
Radiologist Perspective: Which Management Algorithm to Use
Selected References
Miller FH et al: Pancreatic cystic lesions and malignancy: assessment, guidelines, and the Field defect. Radiographics. 42(1):87-105, 2022
Zaheer A: Invited commentary: tears of the pancreas: cry for help. Radiographics. 42(1):E18-20, 2022
Buerlein RCD et al: Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc. 14:26317745211045769, 2021
Lee LS: Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol. 27(34):5700-14, 2021
Vanden Bulcke A et al: Evaluating the accuracy of three international guidelines in identifying the risk of malignancy in pancreatic cysts: a retrospective analysis of a surgical treated population. Acta Gastroenterol Belg. 84(3):443-50, 2021
Lobo JM et al: Clinical and economic outcomes of patients undergoing guideline-directed management of pancreatic cysts. Am J Gastroenterol. 115(10):1689-97, 2020
Hasan A et al: Overview and comparison of guidelines for management of pancreatic cystic neoplasms. World J Gastroenterol. 25(31):4405-13, 2019
Wu J et al: Accuracy of Fukuoka and American Gastroenterological Association guidelines for predicting advanced neoplasia in pancreatic cyst neoplasm: a meta-analysis. Ann Surg Oncol. 26(13):4522-36, 2019
Elta GH et al: ACG clinical guideline: diagnosis and management of pancreatic cysts. Am J Gastroenterol. 113(4):464-79, 2018
European Study Group on Cystic Tumours of the Pancreas.: European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 67(5):789-804, 2018
Takakura K et al: An appraisal of current guidelines for managing malignancy in pancreatic intraductal papillary mucinous neoplasm. JOP. 19(4):178-82, 2018
Lekkerkerker SJ et al: Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome. Gastrointest Endosc. 85(5):1025-31, 2017
Megibow AJ et al: Management of incidental pancreatic cysts: a white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 14(7):911-23, 2017
Sighinolfi M et al: Fukuoka and AGA criteria have superior diagnostic accuracy for advanced cystic neoplasms than Sendai criteria. Dig Dis Sci. 62(3):626-32, 2017
Tanaka M et al: Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 17(5):738-53, 2017
Xu MM et al: Comparison of the diagnostic accuracy of three current guidelines for the evaluation of asymptomatic pancreatic cystic neoplasms. Medicine (Baltimore). 96(35):e7900, 2017
Chiang AL et al: Clinical approach to incidental pancreatic cysts. World J Gastroenterol. 22(3):1236-45, 2016
Ma GK et al: Comparing American Gastroenterological Association pancreatic cyst management guidelines with Fukuoka consensus guidelines as predictors of advanced neoplasia in patients with suspected pancreatic cystic neoplasms. J Am Coll Surg. 223(5):729-737.e1, 2016
American Gastroenterological Association: AGA section. Managing pancreatic cysts: a patient guide. Gastroenterology. 149(2):498-9, 2015
Lennon AM et al: AGA guidelines for the management of pancreatic cysts. Gastroenterology. 149(3):825, 2015
Scheiman JM et al: American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 148(4):824-48.e22, 2015
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References
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KEY FACTS
Terminology
TERMINOLOGY
Definitions
Pancreatic cystic neoplasms encompass broad range of different lesions, including intraductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms (MCNs), serous cystadenomas (SCAs), cystic neuroendocrine tumors (NETs), and variety of additional lesions
Lesions are increasingly being incidentally identified on imaging exams (CT and MR) as imaging technology has improved
Incidence increases with age and may be up to 25% in patients > 70 years of age
No clear consensus on optimal management of these lesions, which requires balance between avoiding overtreatment (as most of these are ultimately benign) and appropriate surveillance/treatment of lesions with greater risk of malignancy
Avoiding unnecessary surgery is important, as surgical mortality during pancreatic resection is 1-7% and morbidity as high as 64%
Pancreatic cysts are extremely common (reported prevalence: 2-38%) with any given cyst estimated to carry frank malignancy in only 0.01% of cases, further emphasizing need to appropriately risk stratify these lesions
Field defect: IPMN may be marker of background parenchymal abnormality indicative of increased risk of invasive pancreatic cancer at other sites within pancreas
Pancreatic Cyst Management Algorithms
5 most commonly utilized management systems include International Association of Pancreatology (IAP) in 2017, American Gastroenterological Association (AGA) in 2015, European Study Group on Cystic Tumors of the Pancreas in 2018, American College of Gastroenterology (ACG) guidelines in 2018, and American College of Radiology (ACR) guidelines in 2017
ACR released management system for pancreatic cysts in 2017, although this system is less commonly utilized in clinical practice (particularly at high-volume pancreatic surgery centers)
Each system has different approaches to pancreatic cysts in terms of type of cysts dealt with, manner of surveillance, and manner of initial evaluation
IMAGING ANATOMY
Most Common Pancreatic Cystic Lesions
Growing Role of EUS
CLINICAL IMPLICATIONS
IAP Guidelines (2017)
AGA Guidelines (2015)
American College of Gastroenterology (ACG) Guidelines (2018)
European Study Group on Cystic Tumors of the Pancreas Guidelines (2018)
ACR White Paper on Incidental Pancreatic Cysts (2017)
Data Comparing Different Cyst Management Algorithms
Radiologist Perspective: Which Management Algorithm to Use
Selected References
Miller FH et al: Pancreatic cystic lesions and malignancy: assessment, guidelines, and the Field defect. Radiographics. 42(1):87-105, 2022
Zaheer A: Invited commentary: tears of the pancreas: cry for help. Radiographics. 42(1):E18-20, 2022
Buerlein RCD et al: Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc. 14:26317745211045769, 2021
Lee LS: Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol. 27(34):5700-14, 2021
Vanden Bulcke A et al: Evaluating the accuracy of three international guidelines in identifying the risk of malignancy in pancreatic cysts: a retrospective analysis of a surgical treated population. Acta Gastroenterol Belg. 84(3):443-50, 2021
Lobo JM et al: Clinical and economic outcomes of patients undergoing guideline-directed management of pancreatic cysts. Am J Gastroenterol. 115(10):1689-97, 2020
Hasan A et al: Overview and comparison of guidelines for management of pancreatic cystic neoplasms. World J Gastroenterol. 25(31):4405-13, 2019
Wu J et al: Accuracy of Fukuoka and American Gastroenterological Association guidelines for predicting advanced neoplasia in pancreatic cyst neoplasm: a meta-analysis. Ann Surg Oncol. 26(13):4522-36, 2019
Elta GH et al: ACG clinical guideline: diagnosis and management of pancreatic cysts. Am J Gastroenterol. 113(4):464-79, 2018
European Study Group on Cystic Tumours of the Pancreas.: European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 67(5):789-804, 2018
Takakura K et al: An appraisal of current guidelines for managing malignancy in pancreatic intraductal papillary mucinous neoplasm. JOP. 19(4):178-82, 2018
Lekkerkerker SJ et al: Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome. Gastrointest Endosc. 85(5):1025-31, 2017
Megibow AJ et al: Management of incidental pancreatic cysts: a white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 14(7):911-23, 2017
Sighinolfi M et al: Fukuoka and AGA criteria have superior diagnostic accuracy for advanced cystic neoplasms than Sendai criteria. Dig Dis Sci. 62(3):626-32, 2017
Tanaka M et al: Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 17(5):738-53, 2017
Xu MM et al: Comparison of the diagnostic accuracy of three current guidelines for the evaluation of asymptomatic pancreatic cystic neoplasms. Medicine (Baltimore). 96(35):e7900, 2017
Chiang AL et al: Clinical approach to incidental pancreatic cysts. World J Gastroenterol. 22(3):1236-45, 2016
Ma GK et al: Comparing American Gastroenterological Association pancreatic cyst management guidelines with Fukuoka consensus guidelines as predictors of advanced neoplasia in patients with suspected pancreatic cystic neoplasms. J Am Coll Surg. 223(5):729-737.e1, 2016
American Gastroenterological Association: AGA section. Managing pancreatic cysts: a patient guide. Gastroenterology. 149(2):498-9, 2015
Lennon AM et al: AGA guidelines for the management of pancreatic cysts. Gastroenterology. 149(3):825, 2015
Scheiman JM et al: American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 148(4):824-48.e22, 2015
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