Pancreatic Cystic Neoplasms: Different Types, Different Management, New Guidelines

Abstract

Pancreatic cystic neoplasms (PCN) include different types of cysts with various biological behavior. The most prevalent PCN are intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and serous cystic neoplasm (SCN). Management of PCN should focus on the prevention of malignant progression, while avoiding unnecessary morbidity of surgery. This requires specialized centers with dedicated multidisciplinary PCN teams. The malignant potential of PCN varies enormously between the various types of PCN. A combination of computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography, and endoscopic ultrasound with or without fine needle aspiration is typically needed before a reliable diagnosis can be made. Several guidelines discuss the management of PCN; however, most of these are non-evidence-based without clear consensus on the optimal treatment and follow-up strategy. The 2018 European guidelines on PCN are the first evidence-based guidelines to include IPMN, MCN, SCN, and all other PCN. This guideline advises a more conservative approach to side-branch IPMN and MCN smaller than 40 mm and more often a surgical approach in IPMN with a main duct dilatation beyond 5 mm. The goal of this review is to summarize the different types and management of the most common PCN based on the current literature and guidelines.

Keywords: Mucinous cyst; Pancreatectomy; Pancreatic cystic neoplasms; Serous cyst.

Fig. 1

Examples of the most common subtypes of pancreatic cystic neoplasms. a Serous cystic neoplasm, b mucinous cystic neoplasm, c side-branch intraductal papillary mucinous neoplasm (IPMN), d main-duct IPMN.

Fig. 2

Indications for surgery. Reproduced from [6] with permission from BMJ Publishing Group Ltd. EUS = Endoscopic ultrasound; IPMN = intraductal papillary mucinous neoplasm.