Case-Based Review

Evaluation and Management of Pancreatic Cystic Lesions

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

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• How are IPMNs diagnosed and managed?

MD-IPMNs harbor a higher risk of malignancy than BD-IPMNs. In one series, 64% of MD-IPMN resected specimens contained cancer [63]. Because of the high cancer risk, all guidelines recommend surgical resection for appropriate patients [6,14,15,16,17]. BD-IPMNs have a lower risk of cancer at diagnosis, present in 19.5% of resected specimens in one study [63]. As a surgical series, this may overstate the true prevalence, which is supported by another study. A cohort of 103 suspected BD-IPMNs patients were observed and those with high-risk features were resected. The overall rate of cancer at 5 years was 2.6%, and only 1 of 103 patients developed non-resectable disease [64]. For these reasons, suspected BD-IPMNs can often be safely monitored if they do not harbor any high risk stigmata as defined by the international consensus criteria (Table 2)[6]. Otherwise, suspected BD-IPMNs are managed in a similar manner to other pancreatic cysts (Table 2) [6,14].

Prognosis after resection is more favorable for IPMNs than for pancreatic adenocarcinoma, possibly due to earlier stage of detection. The 5-year survival for BD-IPMN is 90% after resection, and 47% for MD-IPMN after resection [62]. Survival rates for IPMNs with invasive adenocarcinoma are lower with a combined overall survival 24% to 42% at 5 years. Survival rates are similar to the survival rate for non-cystic pancreatic adenocarcinoma when controlling for size, invasiveness, and lymph node metastasis [65,66].

Guidelines for surveillance after resection have even fewer applicable studies. The 5-year postoperative recurrence rate is 0 to 20% for IPMNs [6]. The revised international consensus guidelines recommends surveillance 6 months after resection with CT or MRI for all IPMNs, but with no recommendation given on how long to continue surveillance [6]. For patients with invasive disease, the same follow up is recommended as for standard invasive adenocarcinoma [6]. The AGA recommends yearly MRI only for only patients with high-grade dysplasia or invasive disease, with consideration for lifelong surveillance [14].

Case 4

A 44-year-old previously healthy female presents with 2 months of epigastric pain. Her laboratory test results, including liver function testing, were normal. A CT of the abdomen and pelvis showed an 11-cm unilocular cyst in the tail of the pancreas ( Figure 4 ). Since the imaging findings were highly suggestive of a MCN, no further workup was done and a laparoscopic spleen preserving distal pancreatectomy was performed. Pathology confirmed a mucinous cystic neoplasm with low-grade dysplasia.

• What is the epidemiology of MCNs and how do they present?

MCNs are mucin-producing lesions (mucinous cysts) of the exocrine pancreas histologically defined by the presence of ovarian stroma [67]. They have the potential to develop into pancreatic adenocarcinoma. Unlike IPMNs, MCNs occur almost exclusively in women, and patients are generally younger. In one series, 99.7% of MCNs occurred in females, with a mean age of 47 [67]. Presenting symptoms, as with other cysts, are often vague. These include abdominal pain, fatigue, weight loss, pancreatitis, and a palpable mass. Only 25% of patients are asymptomatic [68].