Pancreatic Incidentaloma

Abstract

Pancreatic incidentalomas (PIs) represent a clinical entity increasingly recognized due to advances in and easier access to imaging techniques. By definition, PIs should be detected during abdominal imaging performed for indications other than a pancreatic disease. They range from small cysts to invasive cancer. The incidental diagnosis of pancreatic cancer can contribute to early diagnosis and treatment. On the other hand, inadequate management of PIs may result in overtreatment and unneeded morbidity. Therefore, there is a strong need to evaluate the nature and clinical features of individual PIs. In this review, we summarize the major characteristics related to PIs and present suggestions for their management.

Keywords: cysts; early detection; incidentaloma; neoplasm; pancreas; pancreatic cancer; pancreatic tumor.

Figure 1

Subgroups of PIs. It is worth emphasizing that abnormal dilatation of the MPD may coexist with other types of PIs. ACNs, acinar-cell cystic neoplasms; CNNs, cystic neuroendocrine neoplasms; FCP, focal chronic pancreatitis; IPMNs, intraductal papillary mucinous neoplasms; MCNs, mucinous cystic neoplasms; MPCLs, mucinous pancreatic cystic lesions; n-MPCLs, non-mucinous pancreatic lesions; PCLs, pancreatic cystic lesions; PCNs, pancreatic cystic neoplasms; PDAC, pancreatic ductal adenocarcinoma; PIs, pancreatic incidentalomas; pNET, pancreatic neuroendocrine tumor; SCNs, serous cystic neoplasms; SPNs, solid-pseudopapillary neoplasms.

Figure 2

Proposed algorithm of management of incidentally detected cystic lesion in the pancreas based on the European Evidence-Based Guidelines on Cystic Tumors of the Pancreas [2,56]. CT, computed tomography; EUS, endoscopic ultrasound; FNA, fine needle aspiration; HGD, high grade dysplasia; IPMN, intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; MPD, main pancreatic duct; MRI, magnetic resonance imaging; PCL, pancreatic cystic lesion; SCN, serous cystic neoplasm.

Figure 3

Proposed algorithm of management of incidentally detected solid lesion in the pancreas [2]. It is worth emphasizing that the Figure presents a simplified algorithm. It should be noted that differentiation between hypo- and hyperenhancing change is significant at the initial stages of the diagnostic process and may strongly determine further clinical management. For example, hypoenhancing lesion concomitant with upstream dilatation of the main pancreatic duct could be a clear indication for surgery, even without EUS with or without FNA. In turn, surgery should be also considered in the case of hypoenhancing lesion, whose fine needle aspiration biopsy does not exclude the cancer diagnosis. CP, chronic pancreatitis; CT, computed tomography; EUS, endoscopic ultrasound; FNA, fine needle aspiration; Ki-67, antigen KI-67; MRI, magnetic resonance imaging; PDAC, pancreatic ductal adenocarcinoma; pNET, pancreatic neuroendocrine tumor; SL, solid lesion.

Figure 4

Proposed algorithm of management of incidentally detected dilatation of main pancreatic duct in the pancreas [2]. It is worth emphasizing that the assessment of the contours of main pancreatic duct may be significant and potentially indicate a cause of dilatation. Irregular contour with a dilatation of MPD suggests the presence of periductal fibrosis and is crucial sign of chronic pancreatitis. In turn, smooth or beaded dilatation of the main pancreatic duct may result from pancreatic cancer. CP, chronic pancreatitis; IPMN, intraductal papillary mucinous neoplasm; MPD, main pancreatic duct.