Pancreatic Cysts 3 cm or Smaller: How Aggressive Should Treatment Be?

Sahani, Dushyant V.; Saokar, Anuradha; Hahn, Peter F.; Brugge, William R.; Castillo, C. Fernandez-del

doi:10.1148/radiol.2382041806

Cited by 141 publications

(76 citation statements)

References 16 publications

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“…There are no firm guidelines for this situation but the chances of a very small incidental cyst (<1 cm) becoming malignant in a year are likely small. This is being supported by more recent studies (12,66) and will likely be true especially in the case of side-branch IPMN. Hopefully, as we learn more about the natural history of these lesions a surveillance strategy will evolve.…”

Section: Chemistries and Tumor Marker Analysis (Level 2)supporting

confidence: 54%

“…Pancreatoscopy, like ERCP, can distinguish main duct from side-branch IPMN, but in addition may identify papillary projections associated with malignant transformation, and determine the longitudinal extent of tumor (11). Secretin-stimulated magnetic resonance cholangiopancreatogram (MRCP) also provides excellent imaging of the pancreatic duct, including identification of communication between a cystic lesion and the main pancreatic duct, e.g., in the case of branch-duct IPMN (12).…”

Section: Intraductal Papillary Mucinous Neoplasmsmentioning

confidence: 99%

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

Khalid¹,

Brugge²

2007

Am J Gastroenterology

290

197

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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.

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Section: Chemistries and Tumor Marker Analysis (Level 2)supporting

confidence: 54%

Section: Intraductal Papillary Mucinous Neoplasmsmentioning

confidence: 99%

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

Khalid¹,

Brugge²

2007

Am J Gastroenterology

290

197

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“…Distal pancreatectomy is nominated when tumors are located in the body or tail of the pancreas. In addition, a Whipple resection is required when the tumor is situated in the head or uncinate process of the pancreas (13,15). It is widely accepted that close follow-up is recommended in asymptomatic patients with tumors less than 3 cm in maximal diameter, in elderly patients or in those who have high surgical risks.…”

Section: Discussionmentioning

confidence: 99%

“…Authors have suggested that follow-up should be scheduled every 6 months for 2 years and annually following that. The follow-up should be continued for at least 4 years, otherwise patients should no longer be considered as candidates for surgical intervention (13,15). Since SMAs have little or no potential of malignant transformation, the prognosis is considered to be favorable.…”

Section: Discussionmentioning

confidence: 99%

Serous microcystic adenoma of the pancreatic head: Report of two cases and review of the literature

Pu¹,

Tong²,

Zhou³

et al. 2010

Oncology Letters

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Abstract. Serous microcystic adenomas (SMAs), also known as glycogen-rich cystadenomas, are uncommon exocrine tumors mainly involved in the body and tail of the pancreas. In this study, we report two SMA cases of the pancreatic head. In case 1, a 47-year-old woman was referred to our hospital for abdominal bloating and back pain; in case 2, a pancreatic space-occupying lesion was incidentally discovered in an asymptomatic 71-year-old female during an ultrasound. In both cases, a computer tomography scan showed well-demarcated and multilocular cysts in the head of the pancreas, and a central scar and calcifications were noted in case 1. During the exploratory laparotomies, the multiple cystic masses were found in the pancreatic head. A segmental resection of the pancreas and pancreatic jejunal anastomosis were performed. Histologically, the tumors were composed of tiny cysts that were filled with clear fluid and lined by a single layer of cuboidal cells with round, centrally located nuclei and clear cytoplasm, without cellular atypia. Immunohistochemical studies showed that the neoplastic cells were positive for cytokeratin 7 and vimentin but negative for synaptophysin and cytokeratin 20. A postoperative follow-up indicated no recurrence in the patients. We reviewed the literature regarding the etiology, clinical presentation, imaging characteristics, features and management of this lesion.

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“…[14][15][16]20 Although both MCNs and IPMNs are known to have malignant potential, and therefore have historically all been resected, recent studies highlighting slow growth and indolence of many of these neoplastic mucinous cysts 15,17 have led to increased use of nonsurgical alternatives, from close clinical follow-up to in situ ablation. 13,20,[28][29][30][31][32][33] Main duct IPMNs, regardless of symptoms, cytology, or the presence of a mural nodule, are considered high risk for malignancy, and are therefore all resected in surgically fit candidates. 8,34 For patients with suspected branch duct IPMNs or MCNs, recent international consensus guidelines recommend surgical resection for patients with mucinous cysts either >3 cm or smaller cysts with high-risk features such as symptoms, positive cytology, or a mural nodule.…”

Section: Clinical Managementmentioning

confidence: 99%

Pancreatic cysts

Pitman

Lewandrowski

Shen

et al. 2010

Cancer Cytopathology

125

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Preoperative diagnosis of pancreatic cysts benefits from integrating the clinical, radiological, and cytological features. As patient management algorithms evolve to increasingly nonsurgical options, accuracy in distinguishing mucinous from nonmucinous and benign from malignant mucinous cysts is important. This review focuses on pseudocysts, serous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms. Patients with pseudocysts almost always present with pancreatitis and are usually medically managed. Radiological studies reveal a unilocular cyst mostly in the pancreatic tail. Cyst fluid is thin, with high amylase but low carcinoembryonic antigen (CEA) levels. DNA mutations are absent. Serous cystadenomas are benign and do not require resection. Patients are usually asymptomatic and have microcystic or macrocystic masses anywhere in the pancreas. Cytology is frequently nondiagnostic. CEA and amylase levels are low. DNA analysis may reveal loss of heterozygosity (LOH) at 3p if associated with Von Hippel-Lindau disease. Neoplastic mucinous cysts are highly variable in their presentation. Most are resected. Mucinous cystic neoplasms typically arise in the body or tail of the pancreas of middle-aged women and demonstrate a septated cyst without dilatation of the main pancreatic duct. Branch duct IPMNs are more common in the pancreatic head of elderly men. Main duct dilatation correlates with main duct or combined type IPMN. Both types of mucinous cysts produce variable amounts of mucin. Cytologically nonmalignant but atypical epithelial cells, even when scant, are an indication of a high risk for malignancy. High CEA level supports a mucinous cyst, as do KRAS mutation and good quality DNA levels. KRAS mutation and multiple LOH support malignancy.

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Pancreatic Cysts 3 cm or Smaller: How Aggressive Should Treatment Be?

Abstract: The majority (n = 75) of small pancreatic cysts were benign. Thirty-six cysts were unilocular, and virtually all of these (n = 35) were benign. The presence of septa was associated with borderline or in situ malignancy in 20% (10 of 50) of cases.

Cited by 141 publications

References 16 publications

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

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

Serous microcystic adenoma of the pancreatic head: Report of two cases and review of the literature

Pancreatic cysts

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