Endosonography in the diagnosis and management of pancreatic cysts

Abstract

Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no risk of malignancy, neoplastic non-mucinous serous cystadenomas with little or no risk of malignancy, as well as neoplastic mucinous cysts and solid pseudopapillary neoplasms both with varying risk of malignancy. Accurate diagnosis is imperative as management is guided by symptoms and risk of malignancy. Endoscopic ultrasound (EUS) allows high resolution evaluation of cyst morphology and precise guidance for fine needle aspiration (FNA) of cyst fluid for cytological, chemical and molecular analysis. Initially, clinical evaluation and radiologic imaging, preferably with magnetic resonance imaging of the pancreas and magnetic resonance cholangiopancreatography, are performed. In asymptomatic patients where diagnosis is unclear and malignant risk is indeterminate, EUS-FNA should be used to confirm the presence or absence of high-risk features, differentiate mucinous from non-mucinous lesions, and diagnose malignancy. After analyzing the cyst fluid for viscosity, cyst fluid carcinoembryonic antigen, amylase, and cyst wall cytology should be obtained. DNA analysis may add useful information in diagnosing mucinous cysts when the previous studies are indeterminate. New molecular biomarkers are being investigated to improve diagnostic capabilities and management decisions in these challenging cystic lesions. Current guidelines recommend surgical pancreatic resection as the standard of care for symptomatic cysts and those with high-risk features associated with malignancy. EUS-guided cyst ablation is a promising minimally invasive, relatively low-risk alternative to both surgery and surveillance.

Endoscopic ultrasound‐through‐the‐needle biopsy in pancreatic cystic lesions: A multicenter study

“…Pancreatic cystic lesions (PCL) are discovered with increasing frequency as a result of the widespread use of high‐resolution cross‐sectional imaging techniques . At present, no single diagnostic tool has been found to be reliable for the differential diagnosis of PCL, and assessment of the risk of malignant transformation relies on information such as clinical history, results of radiological examinations, endoscopic ultrasound (EUS), cystic fluid analysis, and cytohistological testing …”

“…1,2 At present, no single diagnostic tool has been found to be reliable for the differential diagnosis of PCL, and assessment of the risk of malignant transformation relies on information such as clinical history, results of radiological examinations, endoscopic ultrasound (EUS), cystic fluid analysis, and cytohistological testing. 3,4 Radiological high-resolution cross-sectional imaging studies and EUS-morphology are usually not sufficient to accurately assess the need for surgery or surveillance, especially in cases of unilocular or oligocystic PCL. [4][5][6][7][8] Carcinoembryonic antigen (CEA) cystic fluid levels have limited accuracy and are not useful to confirm or rule out the presence of malignancy.…”

Pancreatectomía distal laparoscópica con preservación del bazo para el tratamiento del tumor pseudopapilar del páncreas: informe de un caso y revisión de la literatura

“…La tomografía es la prueba diagnóstica de elección, pues permite diferenciar los varios tipos de neoplasias quísticas con base en los siguientes criterios: localización, patrón intralesional (unilocular, oligoquístico, poliquístico), calcificaciones, comunicación con el conducto pancreático principal o los ductos laterales, septos y presencia de nódulos murales (13); sin embargo, en años recientes la ecografía endoscópica con o sin aspiración con aguja fina se ha afianzado como estrategia de estudio efectiva y segura en la clasificación de lesiones quísticas y sólidas del páncreas, que da información cuando el diagnóstico no es claro y confirma la presencia o ausencia de características de riesgo o el diagnóstico de malignidad (14,15).…”

Cystic fluid chromogranin A levels in different pancreatic cystic lesions

“…Meticulous investigations showed that this case was not a PNET, and its final diagnosis after surgery was chronic pseudocyst that developed in chronic pancreatitis. Pseudocysts, retention cysts, lymphoepithelial cysts, and benign epithelial cysts are non-neoplastic cysts (26). When we grouped those lesions together, the mean CgA level was slightly higher in those groups compared with neoplastic cysts.…”