Pancreatic Cysts

Question 1

Recommend caution when attributing symptoms to a pancreatic cyst. The majority of pancreatic cysts are asymptomatic and the nonspecific nature of symptoms requires clinical discernment.

Answer 1

conditional, very low evidence

Question 2

MRI or MRCP are the tests of choice b/c of their non-invasiveness, lack of radiation, and greater accuracy in assessing communication b/w the main pancreatic duct and the cyst (which is characteristic of side-branch IPMNs). Pancreatic protocol CT or EUS are excellent alternatives in patients who are unable to undergo MRI. Indeterminate cysts may benefit from a second imaging modality or cyst fluid analysis via EUS.

Answer 2

conditional, very low evidence

Question 3

Use caution when using imaging to diagnose cyst type or concomitant malignancy; the accuracy of MRI or MRCP in diagnosing cyst type is 40-50% and in deterring benign vs. malignant is 55-76%. The accuracy for CT and EUS w/o FNA is similar.

Answer 3

conditional, very low evidence

Question 4

Patients who are not medically fit for surgery shouldn’t undergo further evaluation of incidentally found pancreatic cysts, irrespective of cyst size

Answer 4

strong, low evidence

Question 5

Asymptomatic cysts that are diagnosed as pseudocysts on initial imaging and clinical history, or that have a very low risk of malignant transformation (such as serous cyst adenomas) do not require treatment or further evaluation

Answer 5

conditional, low evidence

Question 6

EUS-FNA and cyst fluid analysis should be considered in cysts in which the diagnosis is unclear, and where the results are likely to alter management. Analysis of cyst fluid CEA may be considered to differentiate IPMNs and MCNs from other cyst types, but cannot be used to identify IPMNs and MCNs w/ high-grade dysplasia or pancreatic cancer.

Answer 6

conditional, very low evidence

Question 7

Molecular markers may help identify IPMNs and MCNs. Their use may be considered in cases in which the diagnosis is unclear and the results are likely to change management.

Answer 7

conditional, very low evidence

Question 8

Cyst surveillance should be offered to surgically fit candidates w/ asymptomatic cysts that are presumed to be IPMNs or MCNs

Answer 8

conditional, very low evidence

Question 9

Patients w/ IPMNs or MCNs w/ new-onset or worsening diabetes mellitus, or a rapid increase in cyst size (of >3mm/yr) during surveillance, may have increased risk of malignancy, so should undergo a short-interval MRI or EUS +/- FNA

Answer 9

conditional, very low evidence

Question 10

Patients w/ IPMNs or MCNs w/ any of the following features should undergo EUS +/- FNA and/or be referred to a multidisciplinary group for further evaluation:

a) jaundice 2/2 the cyst, acute pancreatitis 2/2 the cyst, significantly elevated serum CA 19-9
b) mural nodule or solid component either within the cyst or in the pancreatic parenchyma, dilation of the main pancreatic of >5 mm, a focal dilation of the pancreatic duct concerning for main duct IPMN or an obstructing lesion, mucin-producing cysts measuring >/= 3cm in diameter
c) the presence of high-grade dysplasia or pancreatic cancer on cytology

Answer 10

strong, very low evidence

Question 11

Patients w/ a solid-pseudo papillary neoplasm should be referred to a multidisciplinary group for consideration of surgical resection

Answer 11

strong, low evidence

Question 12

MRCP is the preferred modality for pancreatic cyst surveillance, given lack of radiation and improved delineation of the main pancreatic duct. EUS may also be the primary surveillance tool in patients who cannot or choose not to have MRI scans.

Answer 12

conditional, very low evidence

Question 13

Surveillance should be discontinued if a patient is no longer a surgical candidate

Answer 13

strong, very low evidence

Question 14

It is reasonable to assess the utility of ongoing surveillance in those >75 yo. An individualized approach for those 76-85 yrs should be considered including an informed discussion about surgery.

Answer 14

conditional, very low evidence

Question 15

Patients w/ a surgically resected serous cyst adenoma, pseudocyst, or other benign cysts do not require any follow-up after resection

Answer 15

strong, very low evidence

Question 16

Resected MCNs w/o pancreatic cancer do not require postoperative surveillance

Answer 16

strong, low evidence

Question 17

All surgically resected IPMN require postoperative surveillance

Answer 17

strong, very low evidence

Question 18

Patients should be followed on a yearly basis for at least 5 years following resection of a solid pseudo papillary neoplasm

Answer 18

conditional, very low evidence