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To Cease or ‘De-cyst’? The Evaluation and Management of Pancreatic Cystic Lesions

  • Pancreas and Biliary Tract (O Haluszka, Section Editor)
  • Published:
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Abstract

Due to the widespread use of cross-sectional imaging and advances in imaging technology, pancreatic cystic lesions are increasingly being detected. The diagnosis and management of such cysts remains challenging and continues to evolve. Different pancreatic cyst types have varying malignant potential. Thus, accurate cyst characterization is essential to appropriate management; the most clinically important distinction is differentiating mucinous lesions, which have malignant potential and may benefit from surgical resection, from non-mucinous cystic lesions. Endoscopic ultrasound with fine needle aspiration with cytologic, chemical,, and tumor marker analysis appears to be the best currently available method for accurately characterizing a cyst’s malignant potential, and therefore impacts the most important management decision for a pancreatic cyst—continued surveillance or surgical resection.

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References

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  1. Laffan TA, Horton KM, Klein AP, Berlanstein B, Siegelman SS, Kawamoto S, et al. Prevalence of unsuspected pancreatic cysts on MDCT. AJR Am J Roentgenol. 2008. doi:10.2214/AJR.07.3340.

    PubMed  Google Scholar 

  2. Spinelli KS, Fromwiller TE, Daniel RA, Kiely JM, Nakeeb A, Komorowski RA, et al. Cystic pancreatic neoplasms: observe or operate. Ann Surg. 2004;239(5):651–7.

    Google Scholar 

  3. Zhang XM, Mitchell DG, Dohke M, Holland GA, Parker L. Pancreatic cysts: depiction on single-shot fast spin-echo MR images. Radiology. 2002;223(2):547–53.

    Google Scholar 

  4. Pitman MB. Pancreatic cyst fluid triage: a critical component of the preoperative evaluation of pancreatic cysts. Cancer Cytopathol. 2013. doi:10.1002/cncy.21227.

    Google Scholar 

  5. Kimura W. How many millimeters do atypical epithelia of the pancreas spread intraductally before beginning to infiltrate?. Hepatogastroenterology. 2003;50(54):2218–24.

    Google Scholar 

  6. Lee KS, Sekhar A, Rofsky NM, Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol. 2010. doi:10.1038/ajg.2010.122.

    Google Scholar 

  7. • Canto MI, Hruban RH, Fishman EK, Kamel IR, Schulick R, Zhang Z, et al. Frequent detection of pancreatic lesions in asymptomatic high-risk individuals. Gastroenterology. 2012. doi:10.1053/j.gastro.2012.01.005.

    PubMed  Google Scholar 

  8. Poley JW, Kluijt I, Gouma DJ, Harinck F, Wagner A, Aalfs C, et al. The yield of first-time endoscopic ultrasonography in screening individuals at a high risk of developing pancreatic cancer. Am J Gastroenterol. 2009. doi:10.1038/ajg.2009.276.

    PubMed  Google Scholar 

  9. Canto MI, Goggins M, Hruban RH, Petersen GM, Giardiello FM, Yeo C, et al. Screening for early pancreatic neoplasia in high-risk individuals: a prospective controlled study. Clin Gastroenterol Hepatol. 2006. doi:10.1016/j.cgh.2006.02.005.

    Google Scholar 

  10. Langer P, Kann PH, Fendrich V, Habbe N, Schneider M, Sina M, et al. Five years of prospective screening of high-risk individuals from families with familial pancreatic cancer. Gut. 2009. doi:10.1136/gut.2008.171611.

    PubMed  Google Scholar 

  11. Song SJ, Lee JM, Kim YJ, Kim SH, Lee JY, Han JK, et al. Differentiation of intraductal papillary mucinous neoplasms from other pancreatic cystic masses: comparison of multirow-detector CT and MR imaging using ROC analysis. J Magn Reson Imaging. 2007. doi:10.1002/jmri.21001.

    Google Scholar 

  12. Macari M, Finn ME, Bennett GL, Cho KC, Newman E, Hajdu CH, et al. Differentiating pancreatic cystic neoplasms from pancreatic pseudocysts at MR imaging: value of perceived internal debris. Radiology. 2009. doi:10.1148/radiol.2511081286.

    Google Scholar 

  13. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, Centeno BA, Szydlo T, Regan S, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology. 2004;126(5):1330–6.

    Google Scholar 

  14. Ahmad NA, Kochman ML, Brensinger C, Brugge WR, Faigel DO, Gress FG, et al. Interobserver agreement among endosonographers for the diagnosis of neoplastic versus non-neoplastic pancreatic cystic lesions. Gastrointest Endosc. 2003. doi:10.1067/mge.2003.298.

    PubMed  Google Scholar 

  15. Khashab MA, Kim K, Lennon AM, Shin EJ, Tignor AS, Amateau SK, et al. Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms. Pancreas. 2013. doi:10.1097/MPA.0b013e3182883a91.

    PubMed  Google Scholar 

  16. Lee LS, Saltzman JR, Bounds BC, Poneros JM, Brugge WR, Thompson CC. EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors. Clin Gastroenterol Hepatol. 2005;3(3):231–6.

    Google Scholar 

  17. Frossard JL, Amouyal P, Amouyal G, Palazzo L, Amaris J, Soldan M, et al. Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions. Am J Gastroenterol. 2003. doi:10.1111/j.1572-0241.2003.07530.x.

    PubMed  Google Scholar 

  18. Sedlack R, Affi A, Vazquez-Sequeiros E, Norton ID, Clain JE, Wiersema MJ. Utility of EUS in the evaluation of cystic pancreatic lesions. Gastrointest Endosc. 2002. doi:10.1067/mge.2002.128106.

    PubMed  Google Scholar 

  19. Genevay M, Mino-Kenudson M, Yaeger K, Konstantinidis IT, Ferrone CR, Thayer S, et al. Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts. Ann Surg. 2011. doi:10.1097/SLA.0b013e3182383118.

    PubMed  Google Scholar 

  20. Brandwein SL, Farrell JJ, Centeno BA, Brugge WR. Detection and tumor staging of malignancy in cystic, intraductal, and solid tumors of the pancreas by EUS. Gastrointest Endosc. 2001. doi:10.1067/mge.2001.114783.

    Google Scholar 

  21. Maire F, Couvelard A, Hammel P, Ponsot P, Palazzo L, Aubert A, et al. Intraductal papillary mucinous tumors of the pancreas: the preoperative value of cytologic and histopathologic diagnosis. Gastrointest Endosc. 2003;58(5):701–6.

    Google Scholar 

  22. Jacobson BC, Baron TH, Adler DG, Davila RE, Egan J, Hirota WK, et al. ASGE guideline: The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas. Gastrointest Endosc. 2005;61(3):363–70.

    Google Scholar 

  23. Thosani N, Thosani S, Qiao W, Fleming JB, Bhutani MS, Guha S. Role of EUS-FNA-based cytology in the diagnosis of mucinous pancreatic cystic lesions: a systematic review and meta-analysis. Dig Dis Sci. 2010. doi:10.1007/s10620-010-1361-8.

    PubMed  Google Scholar 

  24. Al-Haddad M, Gill KR, Raimondo M, Woodward TA, Krishna M, Crook JE, et al. Safety and efficacy of cytology brushings versus standard fine-needle aspiration in evaluating cystic pancreatic lesions: a controlled study. Endoscopy. 2010. doi:10.1055/s-0029-1215351.

    Google Scholar 

  25. • Hong SK, Loren DE, Rogart JN, Siddiqui AA, Sendecki JA, Bibbo M, et al. Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts. Gastrointest Endosc. 2012. doi:10.1016/j.gie.2011.12.015. This recent study demonstrates a technique to increase the diagnostic yield in EUS-FNA of pancreatic cysts, which can be highly variable.

    Google Scholar 

  26. van der Waaij LA, van Dullemen HM, Porte RJ. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc. 2005;62(3):383–9.

    Google Scholar 

  27. Chai SM, Herba K, Kumarasinghe MP, de Boer WB, Amanuel B, Grieu-Iacopetta F, et al. Optimizing the multimodal approach to pancreatic cyst fluid diagnosis: developing a volume-based triage protocol. Cancer Cytopathol. 2013. doi:10.1002/cncy.21226.

    PubMed  Google Scholar 

  28. Khalid A, Zahid M, Finkelstein SD, LeBlanc JK, Kaushik N, Ahmad N, et al. Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest Endosc. 2009. doi:10.1016/j.gie.2008.07.033.

    Google Scholar 

  29. Panarelli NC, Sela R, Schreiner AM, Crapanzano JP, Klimstra DS, Schnoll-Sussman F, et al. Commercial molecular panels are of limited utility in the classification of pancreatic cystic lesions. Am J Surg Pathol. 2012. doi:10.1097/PAS.0b013e31825d534a.

    Google Scholar 

  30. Fasanella KE, McGrath K. Cystic lesions and intraductal neoplasms of the pancreas. Best Pract Res Clin Gastroenterol. 2009. doi:10.1016/j.bpg.2008.11.011.

    PubMed  Google Scholar 

  31. Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited. Part I: serous cystic neoplasms. Surg Oncol. 2011. doi:10.1016/j.suronc.2010.12.002.

    Google Scholar 

  32. Johnson CD, Stephens DH, Charboneau JW, Carpenter HA, Welch TJ. Cystic pancreatic tumors: CT and sonographic assessment. AJR Am J Roentgenol. 1988. doi:10.2214/ajr.151.6.1133.

    Google Scholar 

  33. MacCarty RL. Cyst fluid analysis and imaging of pancreatic cystic lesions. AJR Am J Roentgenol. 1995. doi:10.2214/ajr.164.4.7726031.

    Google Scholar 

  34. Song MH, Lee SK, Kim MH, Lee HJ, Kim KP, Kim HJ, et al. EUS in the evaluation of pancreatic cystic lesions. Gastrointest Endosc. 2003. doi:10.1067/mge.2003.238.

    Google Scholar 

  35. Cho W, Cho YB, Jang KT, Kim HC, Yun SH, Lee WY, et al. Pancreatic serous cystadenocarcinoma with invasive growth into the colon and spleen. J Korean Surg Soc. 2011. doi:10.4174/jkss.2011.81.3.221.

    Google Scholar 

  36. Bramis K, Petrou A, Papalambros A, Manzelli A, Mantonakis E, Brennan N, et al. Serous cystadenocarcinoma of the pancreas: report of a case and management reflections. World J Surg Oncol. 2012. doi:10.1186/1477-7819-10-51.

    PubMed  Google Scholar 

  37. Gourgiotis S, Germanos S, Ridolfini MP. Presentation and management of pancreatic cystic neoplasms. J Clin Gastroenterol. 2007. doi:10.1097/01.mcg.0000225684.29841.52.

    PubMed  Google Scholar 

  38. Tseng JF, Warshaw AL, Sahani DV, Lauwers GY, Rattner DW, Fernandez-del Castillo C. Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg. 2005;242(3):413–9.

    Google Scholar 

  39. Strobel O, Z'graggen K, Schmitz-Winnenthal FH, Friess H, Kappeler A, Zimmermann A, et al. Risk of malignancy in serous cystic neoplasms of the pancreas. Digestion. 2003;68(1):24–33.

    Google Scholar 

  40. Butte JM, Brennan MF, Gonen M, Tang LH, D'Angelica MI, Fong Y, et al. Solid pseudopapillary tumors of the pancreas. Clinical features, surgical outcomes, and long-term survival in 45 consecutive patients from a single center. J Gastrointest Surg. 2011. doi:10.1007/s11605-010-1337-1.

    PubMed  Google Scholar 

  41. Reddy S, Cameron JL, Scudiere J, Hruban RH, Fishman EK, Ahuja N, et al. Surgical management of solid-pseudopapillary neoplasms of the pancreas (Franz or Hamoudi tumors): a large single-institutional series. J Am Coll Surg. 2009. doi:10.1016/j.jamcollsurg.2009.01.044.

    Google Scholar 

  42. Valsangkar NP, Morales-Oyarvide V, Thayer SP, Ferrone CR, Wargo JA, Warshaw AL, et al. 851 resected cystic tumors of the pancreas: a 33-year experience at the Massachusetts General Hospital. Surgery. 2012. doi:10.1016/j.surg.2012.05.033.

    Google Scholar 

  43. Jani N, Dewitt J, Eloubeidi M, Varadarajulu S, Appalaneni V, Hoffman B, et al. Endoscopic ultrasound-guided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: a multicenter experience. Endoscopy. 2008. doi:10.1055/s-2007-995364.

    PubMed  Google Scholar 

  44. Pais SA, Al-Haddad M, Mohamadnejad M, Leblanc JK, Sherman S, McHenry L, et al. EUS for pancreatic neuroendocrine tumors: a single-center, 11-year experience. Gastrointest Endosc. 2010. doi:10.1016/j.gie.2009.12.006.

    PubMed  Google Scholar 

  45. Crippa S, Fernandez-Del Castillo C, Salvia R, Finkelstein D, Bassi C, Dominguez I, et al. Mucin-producing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiologic characteristics. Clin Gastroenterol Hepatol. 2010. doi:10.1016/j.cgh.2009.10.001.

    PubMed  Google Scholar 

  46. Pitman MB. Revised international consensus guidelines for the management of patients with mucinous cysts. Cancer Cytopathol. 2012. doi:10.1002/cncy.21235.

    Google Scholar 

  47. Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited. Part III. Intraductal papillary mucinous neoplasms. Surg Oncol. 2011. doi:10.1016/j.suronc.2011.01.004.

    Google Scholar 

  48. Salvia R, Crippa S, Partelli S, Armatura G, Malleo G, Paini M, et al. Differences between main-duct and branch-duct intraductal papillary mucinous neoplasms of the pancreas. World J Gastrointest Surg. 2010. doi:10.4240/wjgs.v2.i10.342.

    PubMed  Google Scholar 

  49. Anand N, Sampath K, Wu BU. Cyst features and risk of malignancy in Intraductal papillary mucinous neoplasms of the pancreas: a meta-analysis. Clin Gastroenterol Hepatol. 2013. doi:10.1016/j.cgh.2013.02.010.

    Google Scholar 

  50. • Tanaka M, Fernandez-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012. doi:10.1016/j.pan.2012.04.004. This manuscript represents the updated Sendai guidelines for the management and surveillance of pancreatic cysts and is a great reference to have on hand, especially the figure demonstrating the surveillance of branch duct IPMN.

    Google Scholar 

  51. • Khalid A, Brugge W. ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts. Am J Gastroenterol. 2007. doi:10.1111/j.1572-0241.2007.01516.x. This ACG guideline document contains a table (table 6) entitled "Common clinical scenarios and frequently asked questions about neoplastic pancreatic cysts" that is great quick reference and addresses many frequently occurring issues that arise in pancreatic cyst diagnosis and management. The guideline also contains excellent representative pictographs of the various pancreatic cysts.

    PubMed  Google Scholar 

  52. Grobmyer SR, Cance WG, Copeland EM, Vogel SB, Hochwald SN. Is there an indication for initial conservative management of pancreatic cystic lesions? J Surg Oncol. 2009. doi:10.1002/jso.21260.

    PubMed  Google Scholar 

  53. Oh HC, Seo DW, Song TJ, Moon SH, do Park H, Soo Lee S, et al. Endoscopic ultrasonography-guided ethanol lavage with paclitaxel injection treats patients with pancreatic cysts. Gastroenterology. 2011. doi:10.1053/j.gastro.2010.10.001.

    Google Scholar 

  54. Oh HC, Seo DW, Song TJ. Resolution of a septated pancreatic cyst by booster endoscopic ultrasonography-guided ablation. J Dig Dis. 2011. doi:10.1111/j.1751-2980.2011.00538.x.

    PubMed  Google Scholar 

  55. DeWitt J, McGreevy K, Schmidt CM, Brugge WR. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study. Gastrointest Endosc. 2009. doi:10.1016/j.gie.2009.03.1173.

    Google Scholar 

  56. DeWitt J, DiMaio CJ, Brugge WR. Long-term follow-up of pancreatic cysts that resolve radiologically after EUS-guided ethanol ablation. Gastrointest Endosc. 2010. doi:10.1016/j.gie.2010.02.039.

    Google Scholar 

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Brintha K. Enestvedt and Nuzhat Ahmad declare that they have no conflict of interest.

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  1. Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L461, Portland, OR, 97239, USA

    Brintha K. Enestvedt

  2. University of Pennsylvania, 1 Civic Center Blvd, Philadelphia, PA, 19104, USA

    Nuzhat Ahmad

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Correspondence to Brintha K. Enestvedt.

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This article is part of the Topical Collection on Pancreas and Biliary Tract

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Enestvedt, B.K., Ahmad, N. To Cease or ‘De-cyst’? The Evaluation and Management of Pancreatic Cystic Lesions. Curr Gastroenterol Rep 15, 348 (2013). https://doi.org/10.1007/s11894-013-0348-y

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