ACG Practice Guidelines for the Diagnosis and Management of Neoplastic Pancreatic Cysts

Abstract

The diagnosis and management of pancreatic cystic lesions is a common problem. At least 1% of hospitalized patients at major medical centers will have a pancreatic cystic lesion on cross sectional imaging. Up to a quarter of all pancreata examined in an autopsy series contained a pancreatic cyst, 16% of which were lined by an "atypical" epithelium and 3% of which had progressed to carcinoma-in-situ (high grade dysplasia). in the past, it was thought these cystic lesions were benign, but increasing evidence points to the cystic lesions as being the origin of some pancreatic malignancies.The most important clinical tools in the diagnosis and management of pancreatic cystic lesions are cross sectional imaging, endoscopic ultrasound, and cyst fluid analysis. The most important differential diagnosis is distinguishing mucinous (pre-malignant) and non-mucinous cystic lesions. The findings of a macrocystic lesion containing viscous fluid rich in CEA are supportive of a diagnosis of a mucinous lesion. Serous lesion are the most common non-mucinous cyst and are characterized by a microcystic morphology, non-viscous fluid and a low concentration of CEA in the cyst fluid.The following document includes a description of neoplastic pancreatic cysts, a critical review of relevant diagnostic tests, and a discussion of treatment options. We have proposed a set of guidelines for the diagnonis and management of patients with neoplastic pancreatic cysts. The guidelines are based on published data backed by an analysis of the quality of the data and are designed to address the most frequent and important clinical scenarios. In addition to providing a summary of the diagnostic data, we offer diagnostic and management suggestions based on 13 common clinical problems. Although the field is rapidly evolving, a set of core principles is provided based on a balance between the risk of malignancy and the benefit of pancreatic resection.

Cystic Neoplasms of the Pancreas

“…21,22 This is also the recommendation of the American College of Gastroenterology guidelines. 22 It should be noted that some authors have proposed that SCA greater than 4 cm should be considered for resection based on the premise they may grow and become unresectable or degenerate into a malignancy 21,23 however this is approach controversial.…”

“…Surgical resection is recommended for all surgically fit patients with MCN based on the rationale that the natural history of this disease is unknown and that the majority of the patients are young and will require years of follow-up with cross-sectional imaging. 6,22 In patients who are older, or frail, observation may be considered. 6 The survival of patients with low, moderate, or high dysplasia in MCN is excellent with 100 % 5-year diseasespecific survival in two large studies.…”

Whole-exome sequencing of neoplastic cysts of the pancreas reveals recurrent mutations in components of ubiquitin-dependent pathways

“…Cyst fluids can easily and safely be obtained from patients with pancreatic cysts by endoscopic aspiration (23)(24)(25)(26)(27)(28). These fluids are often acellular, and therefore not typically useful for cytological diagnosis.…”

Endoscopic ultrasound: an overview of its role in current clinical practice

“…EUS‐FNA sampling of cystic fluid (Fig. 12) distinguishes mucinous from non‐mucinous cysts by measurement of cyst fluid CEA levels with high specificity but does not predict malignancy 38 .…”