GUIDELINES FOR THE MANAGEMENT OF PANCREATIC CYSTS

The growing use of sophisticated abdominal imaging techniques, which has led to a marked increase in the findings of incidental pancreatic cysts, has prompted the American Gastroenterological Association (AGA) to issue new recommendations in the management of asymptomatic neoplastic pancreatic cysts found incidentally during computed tomography (CT) or magnetic resonance imaging (MRI). The guidelines call for restrictions on aggressive follow-up and a higher threshold before using endoscopic ultrasonography and/or surgery to patients with more high-risk features. Limiting invasive evaluations could help to minimize harm to patients and reduce the costs of health-care delivery. The guidelines are published in Gastroenterology.

AGA Recommendations 

The ten guidelines proposed by the American Gastroenterological Association were developed based on a systematic evaluation of the available evidence and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Each of the recommendations is accompanied by either a “strong” or “conditional” statement regarding the strength of the recommendation based on the quality of the evidence, the risks and benefits of the strategy, the values and preferences of patients, and the cost of the approach being recommended.

Surveillance

1. Before starting any pancreatic cyst surveillance program, patients should have a clear understanding of programmatic risks and benefits.
2. Patients with pancreatic cysts < 3 cm without a solid component or a dilated pancreatic duct should undergo MRI for surveillance in 1 year and then every 2 years for a total of 5 years if there is no change in size or characteristics. (Conditional recommendation)
3. Pancreatic cysts with at least two high-risk features, such as size ≥ 3 cm, a dilated main pancreatic duct, or the presence of an associated solid component, should be examined with endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA). (Conditional recommendation)
4. Patients without concerning EUS-FNA results should undergo MRI surveillance after 1 year and then every 2 years to ensure no change in the risk of malignancy. (Conditional recommendation)
5. Significant changes in the characteristics of the cyst, including the development of a solid component, increasing size of the pancreatic duct, and/or diameter ≥3 cm, are indications for EUS-FNA. (Conditional recommendation)
6. The AGA suggests against continued surveillance of pancreatic cysts if there has been no significant change in the characteristics of the cyst after 5 years of surveillance or if the patient is no longer a surgical candidate. (Conditional recommendation)

Surgery

1. Patients with both a solid component and a dilated pancreatic duct and/or concerning features on EUS and FNA should undergo surgery to reduce the risk of mortality from carcinoma. (Conditional recommendation)
2. If surgery is considered for a pancreatic cyst, patients should be referred to a center with demonstrated expertise in pancreatic surgery. (Strong recommendation)

Surveillance After Surgery

1. Patients with invasive cancer or dysplasia in a cyst that has been surgically resected should undergo MRI surveillance of any remaining pancreas every 2 years. (Conditional recommendation)
2. The AGA suggests against routine surveillance of pancreatic cysts without high-grade dysplasia or malignancy at surgical resection. (Conditional recommendation)

“Although based on extensive literature review and synthesis, these recommendations may result in significant controversy because they advocate less frequent follow-up and a higher threshold before offering EUS and/or surgery,” wrote the study authors. “However, consistent utilization should decrease inadvertent harm to patients and reduce the costs of health-care delivery.”

The study authors reported no conflicts of interest.