Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know

Abstract

The prevalence of pancreatic cysts has increased significantly over the last decade, partly secondary to increased quality and frequency of cross-sectional imaging. While the majority never progress to cancer, a small number will and need to be followed. The management of pancreatic cysts can be both confusing and intimidating due to the multiple guidelines with varying recommendations. Despite the differences in the specifics of the guidelines, they all agree on several high-risk features that should get the attention of any clinician when assessing a pancreatic cyst: presence of a mural nodule or solid component, dilation of the main pancreatic duct (or presence of main duct intraductal papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology on pancreatic cyst fluid aspiration. Other important criteria to consider include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9 levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related to the cystic lesion.

Pancreatic Ductal Adenocarcinoma and “Pseudo-IPMN”

“…The presented case of large duct type PDAC combined with cancerization of retention cysts and ectatic ducts of carcinomaassociated obstructive pancreatitis emphasizes the difficulties cystic pancreatic lesions can pose preoperatively for clinicians and postoperatively for pathologists. Especially confusion of non-malignant with malignant entities can put patients at risk of overtreatment or delayed adequate surgery and treatment [10]. In the majority of cases, PDAC appears radiologically and histologically as a solid tumor.…”

Application of Artificial Intelligence in the Management of Pancreatic Cystic Lesions

“…Currently, the two major applications of this technique are diagnosis of cyst type and malignant risk-stratification. Positive cyst fluid cytology is a surgical indication amongst all current guidelines because it is highly specific for lesions harboring advanced neoplasia, although it is of limited sensitivity [ 71 , 72 ] Genomic analysis via NGS of cyst fluid is a well-studied method that lends to improved sensitivity while maintaining high specificity for the diagnosis of mucinous neoplasm and advanced neoplasia. Specifically, the presence of KRAS and GNAS mutations in cyst fluid has enhanced sensitivity and specificity for classifying mucinous lesions when compared with CEA and cytology [ 73 , 74 ].…”

Accurate prediction of histological grading of intraductal papillary mucinous neoplasia using deep learning

“…Lastly, we obtained the Fukuoka high-risk stigmata presence of obstructive jaundice, intraductal mucin, thickened wall and positive preoperative cytology. We determined recommendation to surgery following the guidelines [19] of the American Gastrointestinal Association (2015 AGA , [4]), the American College of Gastroenterology (2018 AGC, [5]), the European Study Group on Cystic Tumours of the Pancreas (2018 European, [6]) and according to the revised Fukuoka criteria (2017 revised Fukuoka, [7]). Recommendation to surgery was set against histologically determined type of tumor and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated.…”