Management Algorithm for Cystic Pancreatic Lesions

Abstract

Cystic pancreatic lesions are common findings in an aging society due to an increasing availability of high-resolution cross-sectional imaging. Although the overall prevalence of malignancy and the rate of malignant conversion are low, especially mucinous pancreatic cystic lesions such as intraductal papillary mucinous neoplasm and mucinous cystic neoplasm harbor significant malignant potential depending on their morphology and size. Recently updated guidelines recommend sophisticated algorithms for initial workup and surveillance based on individual characteristics of the cystic lesion and the patient, thus weighing the lifetime risk for malignancy against the adverse event rate of potentially curative surgery in the light of number and location of cystic lesions, age of the patient, comorbidities, and the resulting life expectancy as well as the effect of repeated follow-up examinations on the patient's quality of life. This article summarizes recommendations from available guidelines and proposes a pragmatic approach to the clinical management of pancreatic cystic lesions.

Keywords: Fukuoka guidelines; High-risk stigmata; Intraductal papillary mucinous neoplasm, IPMN; Pancreatic cyst surveillance; Worrisome features.

Fig. 1

Model for initial management after cyst discovery and how to make a decision on whom to treat immediately, whom to observe, and whom to discharge from surveillance.

Fig. 2

Proposed management algorithm for surveillance of asymptomatic mucinous cystic lesions of the pancreas incorporating recommendations from the American College of Gastroenterology clinical guideline [3] and revisions of the international consensus Fukuoka guidelines [4].