Updates in diagnosis and management of pancreatic cysts

Abstract

Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential. The most common pancreatic cystic neoplasms include serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm. Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound (EUS) or surgical resection. Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass, nodule and dilated main pancreatic duct. EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging. Various cyst fluid markers including carcinoembryonic antigen, glucose, amylase, cytology, and DNA markers help distinguish mucinous from nonmucinous cysts. This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery. For presumed low risk cysts, surveillance strategies will be discussed. Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.

Keywords: Carcinoembryonic antigen; Endoscopic ultrasound-guided fine needle aspiration; Intraductal papillary mucinous neoplasm; Pancreatic cyst; Serous cystadenoma; Surveillance.

Figure 1

Magnetic resonance imaging of microcystic serous cystadenoma in body of pancreas (arrow)[23].

Figure 2

Magnetic resonance imaging and endoscopic ultrasound of mucinous cystic neoplasm appearing unilocular with a thick wall (arrow)[23]. A: Magnetic resonance imaging; B: Endoscopic ultrasound.

Figure 3

Magnetic resonance cholangiopancreatography of main duct intraductal papillary mucinous neoplasm[23].

Figure 4

Magnetic resonance cholangiopancreatography of branch duct intraductal papillary mucinous neoplasm communicating with nondilated main pancreatic duct (arrow)[23].

Figure 5

Magnetic resonance imaging of solid pseudopapillary neoplasm (arrow)[23].

Figure 6

Microbiopsy forceps through endoscopic ultrasound needle.

Figure 7

Superficial vascular network in serous cystadenoma. Courtesy of Mauna Kea Technologies.

Figure 8

Papillary projections in intraductal papillary mucinous neoplasm. Courtesy of Mauna Kea Technologies.