Survey of Experts' Opinions on the Diagnosis and Management of Pancreatic Cystic Neoplasms

Abstract

Objective: To survey experts' opinions in abdominal radiology (radiologists) and pancreas-specialized gastroenterology (pancreatologists) in South Korea regarding diagnosing and managing pancreatic cystic neoplasms (PCNs).

Materials and methods: Between August 25, 2023, and October 5, 2023, an online survey was conducted among members of the Korean Society of Abdominal Radiology and the Korean Pancreatobiliary Association via email invitation.

Results: The responses from 100 radiologists and 41 pancreatologists were analyzed. Of the respondents, 55.3% (78/141) reported seeing more than 50 patients or reading more than 50 exams related to PCN each month. The most common and preferred diagnostic modality for PCN was contrast-enhanced computed tomography (CECT), favored by 87.8% (36/41) of pancreatologists. When discrepancies arose between CECT or magnetic resonance imaging (MRI) and endoscopic ultrasound, 31.2% (44/141) of the respondents opted for multidisciplinary team discussion, whereas 29.1% (41/141) chose short-term follow-up using CECT or MRI. A total of 88.7% (125/141) of the respondents adhered to the 2017 International Association of Pancreatology (IAP) guidelines in their practice. Among the radiologists, 51.0% (51/100) endorsed a cut-off value of 5 mm for enhancing mural nodules, and 22.0% (22/100) supported a 5 mm/2 yr growth rate in the IAP guidelines v.2017. Additionally, 73.0% (73/100) of radiologists favored discontinuing surveillance, whereas 41.5% (17/41) of pancreatologists disagreed with stopping surveillance.

Conclusion: The survey underscores the clinical burden PCN poses and identifies CECT as the foremost diagnostic tool. Variability was noted in the terminology, differential diagnosis, approaches for resolving discrepancies between imaging examinations, and opinions on surveillance discontinuation among the respondents as a whole, as well as between radiologists and pancreatologists. Although the 2017 IAP guidelines are primarily followed, there remains a level of dissatisfaction with risk stratification among radiologists. This highlights the need for more standardized diagnostic algorithms and improved consensus among specialists to address these challenges.

Keywords: Consensus; Cyst; Guideline; Imaging; Intraductal papillary mucinous neoplasm; Pancreas; Pancreatic cystic neoplasm; Recommendation; Surveillance.

Fig. 1. Diagnostic workup for PCN. A: Recommended examination for US-detected PCN in all 141 respondents. B: Situations where 100 radiologists recommend further examinations for findings on CECT. C: Types of recommended examination for PCN with WFs or HRS on CECT as advised by 100 radiologists. PCN = pancreatic cystic neoplasm, US = ultrasound, RAD = radiologists, CE = contrast-enhanced, WF = worrisome feature, HRS = high-risk stigmata, EUS = endoscopic ultrasound, NC = non-contrast, PAN = pancreatologists

Fig. 2. Indications of endoscopic examinations for PCNs. A: Indications for EUS in the evaluation of PCNs by 41 pancreatologists. B: Indications for CE-EUS in the assessment of PCN by 41 pancreatologists. C: Indications for EUS-guided FNA in the management of PCN by 41 pancreatologists. PCN = pancreatic cystic neoplasm, EUS = endoscopic ultrasound, CE = contrast-enhanced, FNA = fine-needle aspiration, WF = worrisome feature, HRS = high-risk stigmata, DM = diabetes mellitus

Fig. 3. Decision-making in cases of discrepancies between CT/MRI and EUS. When faced with conflicting results, 141 respondents opted for a MDT discussion (n = 44) or a short-term FU using CT or MRI instead of prioritizing one imaging modality over another or seeking tissue confirmation. EUS = endoscopic ultrasound, MDT = multidisciplinary team, FU = follow-up, RAD = radiologists, PAN = pancreatologists

Fig. 4. Survey on PCN surveillance from all 141 respondents. A: Responses regarding the discontinuation of PCN surveillance in general. B-D: Responses to the discontinuation of PCN surveillance according to age (B), size, shape, and stability (C), and cytology results (D). PCN = pancreatic cystic neoplasm, RAD = radiologists, PAN = pancreatologists, WF = worrisome feature, HRS = high-risk stigmata, EUS = endoscopic ultrasound, FNA = fine-needle aspiration