Clinical Approach to Incidental Pancreatic Cystic Neoplasm in Outpatient Clinics

Young Sik Woo; Kyu Taek Lee

doi:10.4166/kjg.2017.70.1.13

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Woo and Lee: Clinical Approach to Incidental Pancreatic Cystic Neoplasm in Outpatient Clinics

Review Article

Korean J Gastroenterol 2017;70(1):13-20.

Published online: 4 October 2017

DOI: https://doi.org/10.4166/kjg.2017.70.1.13

Clinical Approach to Incidental Pancreatic Cystic Neoplasm in Outpatient Clinics

Young Sik Woo, Kyu Taek Lee¹

Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea

¹Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Kyu Taek Lee, Division of Gastroenterology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea. Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail: ktcool.lee@gmail.com

Received 8 June 2017 Revised 26 June 2017 Accepted 27 June 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Cystic lesions of the pancreas are increasingly observed due to increased use of abdominal images. The malignant rate of pancreas cystic lesion varies widely between various types. Identification of malignant or high-risk lesions is important when determining the appropriate course of management. Using these image findings, including cyst size, presence of solid components, and pancreatic duct involvement, the 2012 International Association of Pancreatology (IAP) and the 2015 American Gastroenterological Association (AGA) guidelines provide a rationale in identifying higher risk patients requiring further workups using an endoscopic ultrasound (EUS). EUS with fine needle aspiration and cytology allows confirmation of the cyst type and determines the risk of malignancy. Small cysts with no suspicious features may undergo the regular imaging study for regular surveillance due to low risk for malignancy. In this review, the differences between the 2012 IAP and 2015 AGA guidelines are presented, In addition to possible recommendations for management and surveillance.

Keywords: Pancreatic cyst, Pancreatic neoplasms, Endosonography, Endoscopic ultrasound-guided fine needle aspiration

References

1. Edirimanne S, Connor SJ. Incidental pancreatic cystic lesions. World J Surg. 2008; 32:2028–2037.

2. de Jong K, Nio CY, Hermans JJ, et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol. 2010; 8:806–811.

3. de Jong K, Bruno MJ, Fockens P. Epidemiology, diagnosis, and management of cystic lesions of the pancreas. Gastroenterol Res Pract. 2012; 2012:147465.

4. Chang YR, Park JK, Jang JY, Kwon W, Yoon JH, Kim SW. Incidental pancreatic cystic neoplasms in an asymptomatic healthy population of 21,745 individuals: large-scale, single-center cohort study. Medicine (Baltimore). 2016; 95:e5535.

5. Balthazar EJ, Chako AC. Computed tomography of pancreatic masses. Am J Gastroenterol. 1990; 85:343–349.

6. Fernández-del Castillo C, Targarona J, Thayer SP, Rattner DW, Brugge WR, Warshaw AL. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg. 2003; 138:427–423. discussion 433–424.

7. Goh BK, Tan YM, Cheow PC, et al. Cystic lesions of the pancreas: an appraisal of an aggressive resectional policy adopted at a single institution during 15 years. Am J Surg. 2006; 192:148–154.

8. Tanaka M, Chari S, Adsay V, et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology. 2006; 6:17–32.

9. Tanaka M, Fernández-del Castillo C, Adsay V, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012; 12:183–197.

10. Vege SS, Ziring B, Jain R, Moayyedi P. Clinical Guidelines Committee; American Gastroenterology Association. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 2015; 148:819–822. quize12–13.

11. Yoon WJ, Yoon YB, LEE KH, et al. The cystic neoplasms of the pancreas in Korea. Korean J Med. 2006; 70:261–267.

12. Gaujoux S, Brennan MF, Gonen M, et al. Cystic lesions of the pancreas: changes in the presentation and management of 1,424 patients at a single institution over a 15-year time period. J Am Coll Surg. 2011; 212:590–600. discussion 600–603.

13. Madura JA, Wiebke EA, Howard TJ, et al. Mucin-hypersecreting intraductal neoplasms of the pancreas: a precursor to cystic pancreatic malignancies. Surgery. 1997; 122:786–792. discussion 792–793.

14. Ferrone CR, Correa-Gallego C, Warshaw AL, et al. Current trends in pancreatic cystic neoplasms. Arch Surg. 2009; 144:448–454.

15. Shimizu Y, Yamaue H, Maguchi H, et al. Predictors of malignancy in intraductal papillary mucinous neoplasm of the pancreas: analysis of 310 pancreatic resection patients at multiple high-volume centers. Pancreas. 2013; 42:883–888.

16. Hackert T, Fritz S, Klauss M, et al. Main-duct intraductal papillary mucinous neoplasm: high cancer risk in duct diameter of 5 to 9 mm. Ann Surg. 2015; 262:875–880. discussion 880–881.

17. Schmidt CM, White PB, Waters JA, et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg. 2007; 246:644–651. discussion 651–654.

18. Correa-Gallego C, Do R, Lafemina J, et al. Predicting dysplasia and invasive carcinoma in intraductal papillary mucinous neoplasms of the pancreas: development of a preoperative nomogram. Ann Surg Oncol. 2013; 20:4348–4355.

19. Pelaez-Luna M, Chari ST, Smyrk TC, et al. Do consensus indications for resection in branch duct intraductal papillary mucinous neoplasm predict malignancy? A study of 147 patients. Am J Gastroenterol. 2007; 102:1759–1764.

20. Fritz S, Schirren M, Klauss M, et al. Clinicopathologic characteristics of patients with resected multifocal intraductal papillary mucinous neoplasm of the pancreas. Surgery. 2012; 152(3 Suppl 1):S74–S80.

21. Reddy RP, Smyrk TC, Zapiach M, et al. Pancreatic mucinous cystic neoplasm defined by ovarian stroma: demographics, clinical features, and prevalence of cancer. Clin Gastroenterol Hepatol. 2004; 2:1026–1031.

22. Murakami Y, Uemura K, Ohge H, Hayashidani Y, Sudo T, Sueda T. Intraductal papillary-mucinous neoplasms and mucinous cystic neoplasms of the pancreas differentiated by ovarian-type stroma. Surgery. 2006; 140:448–453.

23. Yamao K, Yanagisawa A, Takahashi K, et al. Clinicopathological features and prognosis of mucinous cystic neoplasm with ovarian-type stroma: a multi-institutional study of the Japan pancreas society. Pancreas. 2011; 40:67–71.

24. Park JW, Jang JY, Kang MJ, Kwon W, Chang YR, Kim SW. Mucinous cystic neoplasm of the pancreas: is surgical resection recommended for all surgically fit patients? Pancreatology. 2014; 14:131–136.

25. Chang H, Gong Y, Xu J, Su Z, Qin C, Zhang Z. Clinical strategy for the management of solid pseudopapillary tumor of the pancreas: aggressive or less? Int J Med Sci. 2010; 7:309–313.

26. Goh BK, Tan YM, Cheow PC, et al. Solid pseudopapillary neoplasms of the pancreas: an updated experience. J Surg Oncol. 2007; 95:640–644.

27. Yang F, Jin C, Long J, et al. Solid pseudopapillary tumor of the pancreas: a case series of 26 consecutive patients. Am J Surg. 2009; 198:210–215.

28. Sunkara S, Williams TR, Myers DT, Kryvenko ON. Solid pseudopapillary tumours of the pancreas: spectrum of imaging findings with histopathological correlation. Br J Radiol. 2012; 85:e1140–e1144.

29. Goh BK, Tan YM, Yap WM, et al. Pancreatic serous oligocystic adenomas: clinicopathologic features and a comparison with serous microcystic adenomas and mucinous cystic neoplasms. World J Surg. 2006; 30:1553–1559.

30. Lee SE, Kwon Y, Jang JY, et al. The morphological classification of a serous cystic tumor (SCT) of the pancreas and evaluation of the preoperative diagnostic accuracy of computed tomography. Ann Surg Oncol. 2008; 15:2089–2095.

31. Khurana B, Mortelé KJ, Glickman J, Silverman SG, Ros PR. Macrocystic serous adenoma of the pancreas: radiologic-pathologic correlation. AJR Am J Roentgenol. 2003; 181:119–123.

32. Salvia R, Fernández-del Castillo C, Bassi C, et al. Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg. 2004; 239:678–685. discussion 685–677.

33. Moriya T, Hashimoto Y, Traverso LW. The duration of symptoms predicts the presence of malignancy in 210 resected cases of pancreatic intraductal papillary mucinous neoplasms. J Gastrointest Surg. 2011; 15:762–770. discussion 770–771.

34. Chung JW, Chung MJ, Park JY, et al. Clinicopathologic features and outcomes of pancreatic cysts during a 12-year period. Pancreas. 2013; 42:230–238.

35. Goh BK, Thng CH, Tan DM, et al. Evaluation of the Sendai and 2012 international consensus guidelines based on cross-sectional imaging findings performed for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically treated patients. Am J Surg. 2014; 208:202–209.

36. Sahora K, Mino-Kenudson M, Brugge W, et al. Branch duct intraductal papillary mucinous neoplasms: does cyst size change the tip of the scale? A critical analysis of the revised international consensus guidelines in a large single-institutional series. Ann Surg. 2013; 258:466–475.

37. Uehara H, Ishikawa O, Katayama K, et al. Size of mural nodule as an indicator of surgery for branch duct intraductal papillary mucinous neoplasm of the pancreas during follow-up. J Gastroenterol. 2011; 46:657–663.

38. Das A, Wells CD, Nguyen CC. Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance? Am J Gastroenterol. 2008; 103:1657–1662.

39. Walsh RM, Vogt DP, Henderson JM, et al. Management of suspected pancreatic cystic neoplasms based on cyst size. Surgery. 2008; 144:677–684. discussion 684–685.

40. Serikawa M, Sasaki T, Fujimoto Y, Kuwahara K, Chayama K. Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification. J Clin Gastroenterol. 2006; 40:856–862.

41. Wu BU, Sampath K, Berberian CE, et al. Prediction of malignancy in cystic neoplasms of the pancreas: a population-based cohort study. Am J Gastroenterol. 2014; 109:121–129. quiz 130.

42. Leeds JS, Nayar MN, Dawwas M, et al. Comparison of endoscopic ultrasound and computed tomography in the assessment of pancreatic cyst size using pathology as the gold standard. Pancreatology. 2013; 13:263–266.

43. Zhong N, Zhang L, Takahashi N, et al. Histologic and imaging features of mural nodules in mucinous pancreatic cysts. Clin Gastroenterol Hepatol. 2012; 10:192–198. 198.e1–2.

44. Bick BL, Enders FT, Levy MJ, et al. The string sign for diagnosis of mucinous pancreatic cysts. Endoscopy. 2015; 47:626–631.

45. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology. 2004; 126:1330–1336.

46. Hammel P, Levy P, Voitot H, et al. Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas. Gastroenterology. 1995; 108:1230–1235.

47. Attasaranya S, Pais S, LeBlanc J, McHenry L, Sherman S, DeWitt JM. Endoscopic ultrasound-guided fine needle aspiration and cyst fluid analysis for pancreatic cysts. JOP. 2007; 8:553–563.

48. 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; 62:383–389.

49. Gan SI, Thompson CC, Lauwers GY, Bounds BC, Brugge WR. Ethanol lavage of pancreatic cystic lesions: initial pilot study. Gastrointest Endosc. 2005; 61:746–752.

50. Oh HC, Seo DW, Kim SH, Min B, Kim J. Systemic effect of endoscopic ultrasonography-guided pancreatic cyst ablation with ethanol and paclitaxel. Dig Dis Sci. 2014; 59:1573–1577.

51. Moyer MT, Dye CE, Sharzehi S, et al. Is alcohol required for effective pancreatic cyst ablation? The prospective randomized CHARM trial pilot study. Endosc Int Open. 2016; 4:E603–E607.

52. 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; 70:710–723.

53. Choi JH, Seo DW, Song TJ, et al. Longterm outcomes after endoscopic ultrasound-guided ablation of pancreatic cysts. Endoscopy. 2017 May 16. [Epub ahead of print].

54. DeWitt J. Endoscopic ultrasound-guided pancreatic cyst ablation. Gastrointest Endosc Clin N Am. 2012; 22:291–302. ix-x.

55. Oh HC, Brugge WR. EUS-guided pancreatic cyst ablation: a critical review (with video). Gastrointest Endosc. 2013; 77:526–533.

56. Nougaret S, Reinhold C, Chong J, et al. Incidental pancreatic cysts: natural history and diagnostic accuracy of a limited serial pancreatic cyst MRI protocol. Eur Radiol. 2014; 24:1020–1029.

57. Kwong WT, Hunt GC, Fehmi SM, et al. Low rates of malignancy and mortality in asymptomatic patients with suspected neoplastic pancreatic cysts beyond 5 years of surveillance. Clin Gastroenterol Hepatol. 2016; 14:865–871.

58. Singhi AD, Zeh HJ, Brand RE, et al. American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: a clinicopathologic study of 225 patients with supporting molecular data. Gastrointest Endosc. 2016; 83:1107–1117.e2.

59. Ridtitid W, DeWitt JM, Schmidt CM, et al. Management of branch-duct intraductal papillary mucinous neoplasms: a large single-center study to assess predictors of malignancy and long-term outcomes. Gastrointest Endosc. 2016; 84:436–445.

60. Lekkerkerker SJ, Besselink MG, Busch OR, et al. Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome. Gastrointest Endosc. 2017; 85:1025–1031.

Table 1.

Chracteristics of Pancreatic Cystic Lesions

Type of cyst	Key features	Malignancy rate, %
Intraductal papillary mucinous neoplasm
Main duct	Mucinous. Segmental or diffuse dilatation of MPD.	38–68^9,14–16
	MPD diameter >10 mm is highly suggestive of malignancy and 5–9 mm is moderately suggestive of malignancy.
Branch duct	Mucinous. Communicates with MPD and no MPD dilatation.	12–47^16–20
Mixed	Satisfy criteria for both main duct and branch duct IPMN.	38–65^9,14–16
Mucinous cystic neoplasm	Mucinous. No communication with duct.	10–17^23,24
	Occurs exclusively in middle age female (mean age, 48–55 y).
	Body and tail of pancreas most common locations.
Solid pseudopapillary neoplasm	Rare. Occurs more often in young female (mean age, 30 y).	8–20^26–28
	Large, mixed solid and cystic lesion.
Serous cystic adenoma	Serous. Honeycomb appearance and central scar.	0
	Macrocystic variant appears similar to MCN.

MPD, main pancreatic duct; IPMN, intraductal papillary mucinous neoplasms; MCN, mucinous cystic neoplasm.

Table 2.

Cystic Fluid Analysis for Incidental Pancreatic Cystic Lesion

	Diagnostic performance	Positive result
String sign (>1 cm, >1 sec)	95% specificity⁴⁴	Mucinous
CEA >192 ng/mL	73% sensitivity, 84% specificity⁴⁵	Mucinous
CEA <5 ng/mL	100% sensitivity, 86% specificity^46,47	Serous
Amylase <250 U/L	44% sensitivity, 98% specificity⁴⁸	Exclude pseudocyst
Cytology	Poor sensitivity, high specificity	Malignant

CEA, carcinoembryonic antigen.

Table 3.

Difference between the 2012 IAP and the 2015 AGA Guidelines for the Management of Pancreatic Cysts^9,10

	2012 IAP	2015 AGA
Targeted patients	Suspected MCN and IPMN	All incidental pancreatic cysts
Recommended image modality	Pancreatic protocol CT or MRI	Pancreas MRI with MRCP
Risk factor	High-risk stigmatas
	Obstructive jaundice
	Enhancing solid component
	MPD 10 mm
	Worrisome features	High-risk features
	Cyst >3 cm	Cyst >3 cm
	Thickened/enhancing cyst wall	Associated solid component
	MPD 5–9 mm	Dilatated MPD
	Nonenhancing mural nodule
	Abrupt change in PD caliber with distal pancreatic	c atrophy
Threshold for EUS	1 worrisome feature	At least 2 risk factors
Threshold for surgery	1 high-risk stigmata
Surveillance protocols in unresected cyst	Frequent surveillance based on cyst size	MRI in 1 yr and then every 2 yr
Stopping surveillance in unresected cyst	No recommendation to stop	After 5 yr of stable cyst
		Surgically unfit patients

IAP, International Association of Pancreatology; AGA, American Gastroenterological Association; EUS, endoscopic ultrasonography; MCN, mucinous cystic neoplasm; IPMN, intraductal papillary mucinous neoplasm; CT, computed tomography; MRI, magnetic resonance imaging; MPD, main pancreatic duct; PD, pancreatic duct; MRCP, magnetic resonance cholangiopancreatography.

Table 4.

Recommended Indication for Endoscopic Ultrasound Guided Fine Needle Aspiration of Pancreatic Cysts

Cyst size ≥3 cm

Diameter of main pancreatic duct >5 mm

Solid component

Thickened or enhanced cyst wall

Change of cyst size during surveillance

Table 5.

Recommended Indications for Resection of Pancreatic Cysts in Accordance to the 2012 IAP and the 2015 AGA Guidelines^9,10

Diagnosis	2012 IAP	2015 AGA
MCN	Resection	Resection
MD-IPMN	Resection	Resection ^a
Mixed-IPMN	Resection	Resection ^a
BD-IPMN	Pancreatitis (for relief of symptoms)	Solid component and MPD >5 mm (both on EUS and MRI) and/or concerning features on EUS and EUS-FNA ^b
	Obstructive jaundice
	Solid component
	MPD >10 mm
	Cytologic features of adenocarcinoma
	Definite mural nodule on EUS
	MPD features suspicious for involvement ^c
	>3 cm cyst in young surgically fit patient

IAP, International Association of Pancreatology; AGA, American Gastroenterological Association; MCN, mucinous cystic neoplasm; MD-IPMN, main duct– intraductal papillary mucinous neoplasm; Mixed-IPMN, mixed type-intraductal papillary mucinous neoplasm; BD-IPMN, branch duct– intraductal papillary mucinous neoplasm; MPD, main pancreatic duct; EUS, endoscopic ultrasonography; MRI, magnetic resonance imaging; EUS-FNA, endoscopic ultrasound guided fine needle aspiration.

^a Presence of a nodule or malignant cytologic features

^b Definite mural nodule, positive cytology for malignancy

^c Presence of thickened walls, intraductal mucin, or mural nodules is suggestive of MPD involvement; in their absence, MPD involvement is inconclusive.

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