Recent advances in the diagnostic evaluation of pancreatic cystic lesions

Abstract

Pancreatic cystic lesions (PCLs) are becoming more prevalent due to more frequent abdominal imaging and the increasing age of the general population. It has become crucial to identify these PCLs and subsequently risk stratify them to guide management. Given the high morbidity associated with pancreatic surgery, only those PCLs at high risk for malignancy should undergo such treatment. However, current diagnostic testing is suboptimal at accurately diagnosing and risk stratifying PCLs. Therefore, research has focused on developing new techniques for differentiating mucinous from non-mucinous PCLs and identifying high risk lesions for malignancy. Cross sectional imaging radiomics can potentially improve the predictive accuracy of primary risk stratification of PCLs at the time of detection to guide invasive testing. While cyst fluid glucose has reemerged as a potential biomarker, cyst fluid molecular markers have improved accuracy for identifying specific types of PCLs. Endoscopic ultrasound guided approaches such as confocal laser endomicroscopy and through the needle microforceps biopsy have shown a good correlation with histopathological findings and are evolving techniques for identifying and risk stratifying PCLs. While most of these recent diagnostics are only practiced at selective tertiary care centers, they hold a promise that management of PCLs will only get better in the future.

Keywords: Confocal laser endomicroscopy; Intraductal papillary mucinous neoplasms; Microforceps biopsy; Mucinous cystic neoplasm; Pancreatic cystic lesion; Radiomics.

Figure 1

Current standard of care diagnostic methods are suboptimal in the diagnosis of specific types of pancreatic cystic lesions and risk-stratification of mucinous cysts. PCL: Pancreatic cystic lesion, CEA: Carcinoembryonic antigen, IPMN: Intraductal papillary mucinous neoplasms, MCN: Mucinous cystic neoplasm, SPN: Solid pseudopapillary neoplasm, Cystic-NET: Cystic neuroendocrine tumors, SCA: Serous cystadenoma.

Figure 2

Features identified on endoscopic ultrasound guided needle confocal laser endomicroscopy. IPMN: Intraductal papillary mucinous neoplasms.

Figure 3

Future directions of detection and risk stratification of pancreatic cystic lesion to guide clinical management. PCL: Pancreatic cystic lesion, CEA: Carcinoembryonic antigen, IPMN: Intraductal papillary mucinous neoplasms.