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Management of Pancreatic Cysts
Siva P. Raman, MD
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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

                      1. Miller FH et al: Pancreatic cystic lesions and malignancy: assessment, guidelines, and the Field defect. Radiographics. 42(1):87-105, 2022
                      2. Zaheer A: Invited commentary: tears of the pancreas: cry for help. Radiographics. 42(1):E18-20, 2022
                      3. Buerlein RCD et al: Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc. 14:26317745211045769, 2021
                      4. Lee LS: Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol. 27(34):5700-14, 2021
                      5. 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
                      6. 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
                      7. Hasan A et al: Overview and comparison of guidelines for management of pancreatic cystic neoplasms. World J Gastroenterol. 25(31):4405-13, 2019
                      8. 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
                      9. Elta GH et al: ACG clinical guideline: diagnosis and management of pancreatic cysts. Am J Gastroenterol. 113(4):464-79, 2018
                      10. European Study Group on Cystic Tumours of the Pancreas.: European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 67(5):789-804, 2018
                      11. Takakura K et al: An appraisal of current guidelines for managing malignancy in pancreatic intraductal papillary mucinous neoplasm. JOP. 19(4):178-82, 2018
                      12. 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
                      13. 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
                      14. 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
                      15. Tanaka M et al: Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 17(5):738-53, 2017
                      16. 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
                      17. Chiang AL et al: Clinical approach to incidental pancreatic cysts. World J Gastroenterol. 22(3):1236-45, 2016
                      18. 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
                      19. American Gastroenterological Association: AGA section. Managing pancreatic cysts: a patient guide. Gastroenterology. 149(2):498-9, 2015
                      20. Lennon AM et al: AGA guidelines for the management of pancreatic cysts. Gastroenterology. 149(3):825, 2015
                      21. 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
                      Related Anatomy
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                      Related Differential Diagnoses
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                      References
                      Tables

                      Tables

                      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

                                          1. Miller FH et al: Pancreatic cystic lesions and malignancy: assessment, guidelines, and the Field defect. Radiographics. 42(1):87-105, 2022
                                          2. Zaheer A: Invited commentary: tears of the pancreas: cry for help. Radiographics. 42(1):E18-20, 2022
                                          3. Buerlein RCD et al: Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc. 14:26317745211045769, 2021
                                          4. Lee LS: Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol. 27(34):5700-14, 2021
                                          5. 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
                                          6. 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
                                          7. Hasan A et al: Overview and comparison of guidelines for management of pancreatic cystic neoplasms. World J Gastroenterol. 25(31):4405-13, 2019
                                          8. 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
                                          9. Elta GH et al: ACG clinical guideline: diagnosis and management of pancreatic cysts. Am J Gastroenterol. 113(4):464-79, 2018
                                          10. European Study Group on Cystic Tumours of the Pancreas.: European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 67(5):789-804, 2018
                                          11. Takakura K et al: An appraisal of current guidelines for managing malignancy in pancreatic intraductal papillary mucinous neoplasm. JOP. 19(4):178-82, 2018
                                          12. 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
                                          13. 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
                                          14. 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
                                          15. Tanaka M et al: Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 17(5):738-53, 2017
                                          16. 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
                                          17. Chiang AL et al: Clinical approach to incidental pancreatic cysts. World J Gastroenterol. 22(3):1236-45, 2016
                                          18. 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
                                          19. American Gastroenterological Association: AGA section. Managing pancreatic cysts: a patient guide. Gastroenterology. 149(2):498-9, 2015
                                          20. Lennon AM et al: AGA guidelines for the management of pancreatic cysts. Gastroenterology. 149(3):825, 2015
                                          21. 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