Case-Based Review

Evaluation and Management of Pancreatic Cystic Lesions

Journal of Clinical Outcomes Management. 2015 December;22(12)

Author(s):

References

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From the Department of Medicine, Stanford University School of Medicine, Stanford, CA.

Abstract

Objective: To review the diagnosis and management of pancreatic cystic lesions.
Methods: Narrative review of the literature.
Results: Pancreatic cystic lesions are clinically relevant as some are precursor lesions to pancreatic adenocarcinoma. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms are 2 commonly encountered pre-cancerous pancreatic cysts. Many cysts are identified incidentally due to frequent use of high-resolution CT and MRI imaging technology. Proposed diagnostic and management algorithms exist to guide clinical practice but are limited by a lack of evidence and discordance among various guidelines. New cyst fluid biomarkers are under development to diagnose cyst types and risk of cancer.
Conclusion: Pancreatic cysts are increasingly encountered in clinical practice and represent a growing problem. Diagnostic and management algorithms are available to assist practice but are limited by the available evidence. A multidisciplinary approach is recommended.

In the United States there were an estimated 46,420 new cases of pancreatic cancer in 2014 [1]. Of all major cancers, pancreatic cancer had the lowest 5-year survival rate at 6% [1]. Of the 3 known precursor lesions to pancreas adenocarcinoma, 2 are pancreatic cysts [2]. Correctly identifying those with cancer, those with cancer potential (premalignant), and those that are benign (harboring no malignant potential) can be difficult.

The estimated prevalence of pancreatic cysts is approximately 2.6% [3]. In some case series using magnetic resonance imaging (MRI), higher rates of detection of approximately 13.5% have been observed [4]. The prevalence increases with age reaching nearly 10% by the 8thdecade of life [3,4]. Mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs) account for about 30% of pancreatic cysts [5]. These cysts are defined as mucinous cysts and are known precursor lesions to pancreatic adenocarcinoma [6]. The other most common types of cysts are serous cystic neoplasms (SCNs), comprising 20% of pancreatic cysts, and pseudocysts, comprising 30% [5]. These cysts are considered nonmucinous cysts and are almost always benign [7,8]. There are multiple other pancreatic cyst types to consider, which are summarized in Table 1 [9,10,11]. In this review, we will cover the diagnosis and management of the most common pancreatic cysts in a case-based format.

Case 1

A 57-year-old male had a 1.5-cm pancreatic cyst located in the head that was found on computed tomography (CT) imaging for suspected renal colic. He had no history or complaints suspicious for pancreatic disease. A CT pancreas protocol scan was obtained, which demonstrated a simple appearing cyst with no mural nodules. The pancreatic and biliary ducts were normal. His laboratory evaluations including liver function testing and lipase were normal.

• What is the approach to incidentally discovered pancreatic cysts?

While many pancreatic cysts are first discovered by cross sectional imaging (CT or MRI), the diagnostic accuracy of defining cyst type and the presence of malignancy is imperfect. The area under the curve (AUC) for differentiating malignant from benign pancreatic cysts ranges from 0.64 to 0.82 for CT and 0.73 to 0.91 for MRI, and no difference between the 2 were observed [12,13]. Several guidelines are currently available to offer guidance on management [6,14,15,16,17]. Much of the current evidence includes retrospective case series with no randomized control trials. The guidelines, therefore, mostly represent consensus-based expert extrapolation of available data.