Evaluation and Management of Pancreatic Cystic Lesions
Journal of Clinical Outcomes Management. 2015 December;22(12)
References
• What interventions exist for treating pancreatic cysts?
Surgery is the mainstay of treatment for pancreatic cysts. The most common surgical procedure for worrisome cysts in the head of the pancreas is a pancreatoduodenectomy (Whipple procedure). For cysts in the distal pancreas, a laparoscopic distal pancreatectomy can be performed [52,53]. Middle pancreatectomy, total pancreatectomy, and enucleation are less commonly performed and remain under investigation. The most common complications after surgery are surgical site and nonsurgical site infection, bleeding, pancreatic fistula, and delayed gastric emptying [52,53]. Overall complication rate for pancreatic cyst surgery is 27% to 39%, and perioperative mortality is 0.5% to 4% at high-volume centers [52,53].
An area of active investigation involves EUS-directed chemical cyst ablation. Prior studies using ethanol intra-cystic injection alone showed cyst resolution in 33% of patients [54]. A combination of ethanol and paclitaxel showed cyst resolution in 62% of patients [55]. Though these techniques offer a less invasive alternative to surgery, the complete eradication of dysplastic cystic epithelium remains uncertain and long-term efficacy is unclear. Thus, these techniques should only be considered in the context of a clinical trial or perhaps in patients who are not surgical candidates [56].
Case 3
A 72-year-old male with a history of pancreatitis 23 years ago complicated by a pseudocyst, who is status post cyst jejunostomy and cholecystectomy presented for evaluation. He was having colicky abdominal pain consistent with prior episodes of nephrolithiasis, and a non-contrast CT scan was obtained that showed a cystic mass in the head of the pancreas. His laboratory test results including liver function tests and lipase were normal. A CT pancreas protocol was obtained and showed a 2.4 x 4.6 cm cystic lesion without mural nodules in the head of pancreas ( Figure 3 ). The cyst was continuous with the main duct, which was dilated to 0.9 cm and the common bile duct was dilated to 1.4 cm. There was severe atrophy of the pancreas upstream of the cyst, and small mesenteric lymph nodes. An endoscopic ultrasound with FNA showed similar findings to the CT, but a CEA was measured at 2298 ng/mL (Figure 3). Given the concerning imaging findings and an elevated CEA, a Whipple procedure was performed and final pathology showed a main-duct IPMN with in situ carcinoma.
• What is the epidemiology of IPMNs and how do they present?
IPMNs are mucin-producing lesions (mucinous cysts) of the exocrine pancreas involving either the main or branch ducts that have the potential to develop into pancreatic adenocarcinoma [57]. The mean age at presentation for both branch duct IPMNs (BD-IPMNs) and main duct IPMNs (MD-IPMNs) is around 65 years [58,59]. In the United States, the male to female prevalence ratio is equal, though there is some geographic variation among different countries [58]. Risk factors for IPMN formation include diabetes, chronic pancreatitis, and a family history of pancreatic adenocarcinoma [60]. Presentation is often asymptomatic but may present with pancreatitis, abdominal pain, weight loss, jaundice, and pancreatic exocrine insufficiency [61]. They tend to occur in the pancreatic head [29]. IPMNs involve either the main pancreatic duct or branch duct or both [62], but this is not always visible by imaging [21]. MRI with MRCP is considered superior to CT in characterizing these lesions, specifically in identifying a connection with the pancreatic ducts [21].
