Cystic Pancreatic Lesions: What You Need to Know
Cystic Pancreatic Lesions: What You Need to Know |
The Cystic Pancreatic Mass: Differential Dx
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Detection of an Incidental Pancreatic Mass
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“ In this outpatient population, the prevalence of unsuspected pancreatic cysts identified on 16-MDCT was 2.6%. Cyst presence strongly correlated with increasing age and the Asian race.” Prevalence of Unsuspected Pancreatic Cysts on MDCT Laffan TA, Horton KM, Fishman EK, Hruban RH AJR 2008;802-807 |
19.8% of Patients had a Pancreatic Cyst Incidentally Discovered  |
Pseudocyst Key distinguishing features:
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Pancreatic Pseudocyst
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Pancreatic Pseudocyst Most common locations:
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Pancreatic Pseudocyst  |
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Pancreatic Pseudocyst  |
IPMN (Intraductal Papillary Mucinous Neoplasm): Facts
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IPMN (Intraductal Papillary Mucinous Neoplasm): Facts Predictors of malignancy in IPMN include
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Multiple IPMNs  |
Multiple IPMNs  |
Incidental Finding  |
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Patient Management
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2017 Revision  |
Categories
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How long do you need to follow these patients? For most patients, we advocate 9- to 10-year follow- up, terminating at the age of 80 years For patients who are <65 years old at the time of initial cyst detection, a follow-up terminating at age 80 will exceed the 9- to 10-year length, but may be prudent ;such decisions regarding additional follow-up should be determined at the individual patient level. |
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923.  |
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923.  |
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923.  |
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923.  |
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923.  |
“The natural history of incidental pancreatic cysts remains uncertain, and our recommendations cannot be simple or entirely definitive. Since 2010, several multi-institutional and specialty society consensus papers, meta-analyses, and large-scale observational studies have appeared but the quality of evidence has been characterized as poor or inconclusive, and conclusions remain controversial.” Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923. |
Five Common Principles of our Algorithm (1) All incidental cysts should be presumed mucinous, unless the cyst has definitive features of an alternative histology (eg, SCA) or has been proven by aspiration not to be mucinous. Such presumed mucinous cysts should be followed or considered for surgery. We generally recommend 9- to 10-year follow-up with varying schedules, based on initial size. If a cyst grows, the frequency of follow-up should increase and/or EUS with FNA should be considered. |
Five Common Principles of our Algorithm (2) Cyst size directs follow-up or intervention. Although our cyst size thresholds (ie, <1.5 cm, 1.5-2.5 cm, >2.5 cm) differ from the commonly used 3 cm threshold, our choices are sensitive to studies of surgically resected “Sendai-negative” cysts <3 cm, which have shown that high-grade dysplasia or frank malignancy may occur in cysts of this size. |
Five Common Principles of our Algorithm (3) Because the flowcharts apply to a range of cyst sizes, growth may require shifting from one flowchart to another, most commonly when a cyst grows from <1.5 to >1.5 cm. Such shifts may also be appropriate when a cyst is first discovered in patients who are close to 80 years of age, as described above). In general, a new 9- to 10-year follow-up period is not recommended when such a shift occurs; rather, decisions concerning total follow-up length should be tailored to the patient’s circumstance. Alternatively, it is appropriate to consider direct sampling of a growing cyst (ie, EUS and FNA). |
Five Common Principles of our Algorithm 4) Development of “worrisome features” or “high-risk stigmata,” as described above (“Reporting Considerations” section), should prompt EUS/FNA and surgical consultation. The exception is that cysts ≥3 cm without any additional “worrisome features” or “high-risk stigmata” can alternatively be followed. |
Five Common Principles of our Algorithm (5) Comparison with prior imaging studies is crucial, including those where the pancreas is frequently visualized, such as chest CT, spine CT or MRI, PET/ CT, and abdominal ultrasound. Prior studies should be reviewed for stability and features. The date of a prior study can be used as a baseline to establish a follow-up schedule. |
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“The MPCC altered the management of a third of patients assessed in the clinic. In the majority of cases, surveillance was recommended, with surgery recommended in just under 10 % of all patients, although no further follow-up was required in just under 2 % of patients who had benign disease. None of the patients in whom the recommendation was changed from surgery to surveillance developed evidence of malignancy during follow-up.” Role of a Multidisciplinary Clinic in the Management of Patients with Pancreatic Cysts: A Single-Center Cohort Study Lennon AM, Manos LL, Hruban RH, Ali SY, Fishman EK et al. Ann Surg Oncol DOI 10.1245/s10434-014-3739 |