Cystic Lesions of the Pancreas: A Diagnostic and Management Dilemma |
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| Institution: | 1. Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, New York, USA;2. Sloan-Kettering Institute, Monoclonal Antibody Core Facility, Memorial Sloan-Kettering Cancer Center, New York, New York, USA;3. Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA;4. Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA;5. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA;1. Gastroenterology Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;2. Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;3. Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;1. Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida;3. Programa de Doctorat en Medicina de la Universitat Autònoma de Barcelona, Barcelona, Spain;4. Department of Radiology, Mayo Clinic, Jacksonville, Florida;6. Department of General Surgery, Mayo Clinic, Jacksonville, Florida;1. Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio;3. Department of Internal Medicine, The Ohio State University, Columbus, Ohio;4. Division of Surgical Oncology, The Ohio State University, Columbus, Ohio;6. Department of General Surgery, The Ohio State University, Columbus, Ohio;5. Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio;1. Yale Pancreas Center and Interventional Endoscopy, Yale School of Medicine, New Haven, Connecticut;2. Pancreas and Biliary Surgery Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;3. Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California;4. Department of Internal Medicine, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California |
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| Abstract: | Background/Aims: Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management. Methods: A search was undertaken with a Pubmed database to identify all English articles using the keywords ‘pancreatic cysts’, ‘serous cystadenoma’, ‘intraductal papillary mucinous tumour’, ‘pseudocysts’, ‘mucinous cystic neoplasm’ and ‘solid pseudopapillary tumour’. Results: The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones. Conclusion: In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. |
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