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What are the main points to note in the management and monitoring of pancreatic cysts?

 Last Update: 2023-01-06
 Source: Internet
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With the advancement of medical imaging, the detection rate of pancreatic cysts has been greatly improved
.
The risk of malignant transformation of pancreatic cysts is small, and the risk of surgical treatment is high, how should further diagnostic and treatment measures be taken for such patients clinically?

A recent review published in Clinical Gastroenterology and Hepatology provides some practical strategies for the management and monitoring of pancreatic cysts, and the highlights are compiled below in the hope that they will be useful
in your clinical work.

The major guidelines point to the importance of
determining cyst classification and risk of tumor formation.

There is no risk of progression in pseudocysts or serous cystadenomas, whereas mucinous cystic tumors and intraductal papillary mucinous tumors (IPMNs) have malignant potential
.
Pancreatic solid tumors can undergo cystic changes and are therefore both solid and cystic.

Patients with pseudocysts usually have a history of
pancreatitis.

The cyst fluid has high amylase levels and low carcinoembryonic antigen (CEA) levels (< 5 ng/mL).

Serous cystadenomas typically present as a single cyst or multiple small cysts without communication with the main pancreatic duct
.

Cystic fluid analysis CEA levels are low
.

Evidence for the von Hippel-Lindau (VHL) tumor suppressor gene confirms a diagnostic sensitivity of 46% and specificity of 100%.

Mucinous cystic tumors usually occur only in women, are mostly located in the body or tail of the pancreas, and are single cysts
without pancreatic duct communication.

Mucinous cystic tumors and IPMNs may have KRAS (mucinous cystic tumors and IPMNs) or GNAS (IPMNs only) mutations
.

MRI is the radiological test
of choice to accurately assess the relationship between the cyst and the main pancreatic duct.

Endoscopic ultrasound (EUS) is invasive, but it is the most sensitive assay for cytology and cystic fluid analysis
.
However, EUS is usually reserved
when management policies need to be changed.

High-risk features of IPMNs include jaundice due to cyst-related biliary compression, pancreatic duct ≥ 10 mm, parietal nodules 5 mm, or solid masses and/or high cytopathic dysplasia or cancer
.

Worrisome features of pancreatic tumors include acute pancreatitis, parietal nodules < 5 mm, main pancreatic duct 5 to 9 mm, sudden changes in pancreatic duct diameter, elevated serum CA 19 to 9 levels, cysts > 3 cm, or rapid increase in volume (2.
5 to 5 mm/year).

Repeat imaging and shorten the monitoring interval
should be ensured in patients with new-onset diabetes.

Patients at high risk or with worrisome features should be evaluated
for EUS by fine-needle aspiration (FNA).

Cysts >3 cm should be subject to surgical referral
.
Excision
is usually performed only on lesions > 4 cm or lesions with other high-risk features.

Monitoring after resection (if performed)
is not recommended for pseudocysts, serous cystadenomas, or mucinous cystic tumors.

However, monitoring of patients with IPMN and residual pancreas is recommended
.
Most recommendations are once every 2 months for 2 years, or once a year if hyperplasia is evident
.

Although monitoring can be stopped if the patient is older than 75 years, the risks and benefits should be assessed and discussed with the patient
.

If the size of the cyst has not changed for at least 5 years, it is also recommended to stop monitoring; The range given by the guide is 5~10 years
.

Invasive evaluation is potentially harmful, and the costs associated with the treatment of pancreatic cysts are high
.
Appropriate evaluation should be chosen and unnecessary monitoring and excision
should be minimized.

References:

1.
David A.
Johnson.
13 Tips for Pancreatic Cyst Surveillance - Medscape - Jul 20, 2022.

2.
Lennon A M, Vege S S.
Pancreatic Cyst Surveillance[J].
Clinical Gastroenterology and Hepatology, 2022.

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