Diagnosis and management of pancreatic cystic lesions for the non-gastroenterologist

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Figure 1
Strategy to evaluate and manage pancreatic cystic lesions.

TABLE 1

Characteristics of neoplastic pancreatic cystic lesions

Characteristic	Serous cystic neoplasms	Solid pseudo- papillary tumors	Mucinous cystic neoplasms	Intraductal papillary mucinous neoplasms	Cystic pancreatic endocrine neoplasm	Pancreatic ductal adenocarcinoma
Malignant potential	Benign	Can progress to malignancy			Malignant
Age group	50–60	20–30	40–50	60–70	50–60	60–70
Sex predilection	Female more often than male			None
Characteristic findings on cross-sectional imaging (computed tomography or magnetic resonance imaging)	Multicystic with central stellate scar	Solid growth with cystic degeneration	Solitary, unilocular, found in body or tail	Multifocal, communicates with main pancreatic duct, dilated main pancreatic duct	Complex cystic mass, enhancement of the cyst wall, hypervascular rim, found in body or tail	Irregular hypoechoic mass associated with an abrupt cutoff of the main pancreatic duct with upstream dilation
Endoscopic ultrasonography-guided fine needle aspiration cyst fluid analysis	Lower carcinoembryonic antigen (< 5 ng/mL), higher glucose, lower amylase	Not applicable	Higher carcinoembryonic antigen (> 192 ng/mL), lower glucose (< 50 mg/dL), positive mucin stain		Not applicable
Treatment	No intervention is recommended if asymptomatic	Surveillance with or without resection			Resection

TABLE 2

High-risk and worrisome features in intraductal papillary mucinous neoplasms

High-risk features	Worrisome features
Main pancreatic duct size ≥ 10 mm	Main pancreatic duct size 5–9 mm
Obstructive jaundice and cyst in head of pancreas	Cyst ≥ 3 cm
Solid mass	Lymphadenopathy
Cancer or high-grade dysplasia on cytology	Elevated carbohydrate antigen 19-9 level
Mural nodule ≥ 5 mm	Mural nodule < 5 mm
	Cyst growth ≥ 5 mm/2 years
	Change in caliber of main pancreatic duct with distal pancreatic atrophy
	Thickened or enhancing cyst walls
	New-onset diabetes mellitus

TABLE 3

Approach to surveillance of pancreatic cystic neoplasms based on the different society guidelines

Cyst size	IAP⁶ (Kyoto), 2023	ACG,⁷ 2018	AGA,⁹ 2015	ACR,⁸ 2017	European consensus,¹⁰ 2018^a
< 1 cm	CT/MRI or EUS in 6 months and then every 18 months if stable	MRI every 2 years for 4 years	MRI in 1 year, then every 2 years for 5 years Stop if no significant change in the characteristics of the cyst after 5 years of surveillance	MRI/CT every 1 year for cysts 1.5 cm to < 2 cm and every 6 months for cysts 2.0–2.5 cm for 4 times, then lengthen the interval Stop after stability over 10 years	Surveillance every 6 months for 2 times with MRI with or without EUS or CA19-9 If stable, lifelong surveillance is recommended with annual MRI/EUS or CA19-9
1–2 cm		MRI every 1 year for 3 years then every 2 years for 4 years
2–3 cm	CT/MRI or EUS every 6 months for 2 times and then every 12 months if stable	MRI/EUS every 6 months–1 year for 3 years then every year for 4 years		For cysts ≥ 2.5 cm, MRI/ CT every 6 months for 4 times, and if stable over initial 2 years, MRI/CT yearly for 2 times, then every 2 years for 3 times, then stop if stable over 10 years For patients age ≥ 80, imaging every 2 years for 2 times, and stop if cyst is stable
> 3 cm	CT/MRI or EUS every 6 months	MRI/EUS every 6 months for 3 years then every year for 4 years	Pursue EUS-FNA

↵a European consensus = European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy.
ACG = American College of Gastroenterology; ACR = American College of Radiology; AGA = American Gastroenterological Association; CA = carbohydrate antigen; CT = computed tomography; EUS = endoscopic ultrasonography; FNA = fine-needle aspiration; IAP = International Association of Pancreatology; MRI = magnetic resonance imaging