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World Journal of Surgery

Published in:

01-09-2008

Incidental Pancreatic Cystic Lesions

Authors: Senarath Edirimanne, Saxon J. Connor

Published in: World Journal of Surgery | Issue 9/2008

Abstract

Introduction

Incidental pancreatic cystic lesions (IPCL) are becoming an increasingly frequent clinical entity. Within this review, the differential diagnosis, investigation, and management are discussed.

Methods

A MEDLINE search was performed for IPCL.

Results

Incidence of IPCL varies from 0.2–0.7%, and 30–47% are premalignant or malignant. Pancreatic pseudocysts (PC), serous cystic neoplasms (SCN), intraductal papillary mucinous neoplasms (IPMN), and mucinous cystic neoplasms (MCN) are the most common pathological entities of IPCL. The use of combined modalities, including clinical characteristics, serum tumor markers, cross-sectional imaging, and endoscopic ultrasound (EUS) with cyst fluid analysis should all be used to establish an accurate preoperative diagnosis if possible. Modern multidetector computed tomography (MDCT) and magnetic resonance pancreatography (MRP) allow detailed characterization of IPCL, including size, septation, calcifications, mural nodules, and communication with main pancreatic duct. The best available cyst fluid markers of mucinous neoplasm are viscosity ≥1.6 and carcinoembryonic antigen >192 ng/ml. Although surgery is indicated for MCN or main or mixed duct IPMN, recent advances in the understanding of the natural history and increasingly accurate preoperative diagnosis allow a nonoperative approach to be undertaken for the majority of IPCL. For those treated nonoperatively, the ideal follow-up has yet to be determined.

Conclusions

Emerging evidence supports selective nonoperative management for the majority of patients who have IPCL when investigated by a multimodal approach. For those in whom a suspicion of malignancy remains, surgery is indicated.

Fernandez-del Castillo DF, Targarona J, Thayer SP et al (2003) Incidental pancreatic cysts: clinicopathological characteristics and comparison with symptomatic patients. Arch Surg 138:427–434PubMedCrossRef

Goh BKP, Tan Y, Cheow P et al (2006) Cystic lesions of pancreas: an appraisal of aggressive resectional policy adopted at a single institution during 15 years. Am J Surg 192:148–154PubMedCrossRef

Spinelli KS, Fromwiller TE, Daniel RA et al (2004) Cystic pancreatic neoplasms: observe or operate. Ann Surg 239:651–659PubMedCrossRef

Walsh RM, Vogt DP, Henderson JM et al (2005) Natural history of indeterminate pancreatic cysts. Surgery 138:665–671PubMedCrossRef

Allen PJ, D’Angelica M, Gonen M et al (2006) A selective approach to the resection of cystic lesions of the pancreas: results of 539 consecutive patients. Ann Surg 244:572–582PubMed

Lee SH, Shin CM, Park JK et al (2007) Outcome of cystic lesions in the pancreas after extended follow-up. Dig Dis Sci 52:2653–2659PubMedCrossRef

Salvia R, Crippa S, Falconi M et al (2007) Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate. Gut 56:1086–1090PubMedCrossRef

Kimura W, Nagai H, Kurodu A (1995) Analysis of small cystic lesions of the pancreas. Int J Pancreatol 18:197–206PubMed

Yoda Y, Suzuki Y, Yamada K et al (1992) A study of mass survey for pancreatic tumour using ultrasonography [in Japanese]. J Gastroenterol Mass Surv 96:50–55

10.

Sahani DV, Kadavigere R, Saokar A et al (2005) Cystic pancreatic lesions: a simple image based classification system for guiding management. Radiographics 25:1471–1484PubMedCrossRef

11.

Andren-Sandberg A, Ansorge C, Eiriksson K et al (2005) Treatment of pancreatic pseudocysts. Scand J Surg 94:164–165

12.

Le Borgne J, de Calan L, Partenski C et al (1999) Cystadenoma and cystadenocarcinoma of the pancreas: multi-institutional retrospective study of 398 cases. French surgical association. Ann Surg 230:152–161PubMedCrossRef

13.

Planner AC, Anderson EM, Slater A et al (2007) An evidence based review for the management of cystic pancreatic lesions. Clin Radiol 62:930–937PubMedCrossRef

14.

Curry CA, Eng J, Horton KA et al (2000) CT of primary pancreatic neoplasms: can CT be used for patient triage and treatment? AJR Am J Roentgenol 175:99–103PubMed

15.

Procacci C, Biastiutti C, Carbognin G et al (1999) Characterization of cystic tumours of the pancreas: CT accuracy. J Comput Assist Tomogr 23:906–912PubMedCrossRef

16.

Procacci C, Graziani R, Bicego E et al (1997) Serous cystadenoma of pancreas: report of 30 cases with emphasis on imaging findings. J Comput Assist Tomogr 21:373–382PubMedCrossRef

17.

Box JC, Douglas HO (2000) Management of cystic neoplasms of the pancreas. Am Surg 66:495–501PubMed

18.

Fernandez-del Castillo DF, Warshaw AL (2000) Current management of cystic neoplasms of pancreas. Adv Surg 34:237–248PubMed

19.

George DH, Murphy F, Michalski R et al (1989) Serous cystadenocarcinoma of the pancreas: a new entity? Am J Surg Pathol 13:61–66PubMedCrossRef

20.

Tseng JF, Warshaw AL, Sahani DV et al (2005) Serous cystadenoma of the pancreas: tumour growth rate and recommendations for treatment. Ann Surg 242:413–419PubMed

21.

Ohashi KM, Maruyama Y (1982) Four cases of mucin producing cancer of the pancreas on specific findings of the ampulla of Vater [in Japanese]. Prog Dig Endosc 20:348–351

22.

Tanaka M, Chari S, Adsay V et al (2006) International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32PubMedCrossRef

23.

Salvia R, Fernandez-del Castillo C, Bassi C et al (2004) Main duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg 239:678–687PubMedCrossRef

24.

Matsumoto T, Aramaki M, Yada K et al (2003) Optimal management of the branch duct type of the intraductal papillary neoplasms of the pancreas. J Clin Gastroenterol 36:261–265PubMedCrossRef

25.

Sugiyama M, Izumisato Y, Abe N et al (2003) Predictive factors for malignancy in intraductal papillary mucinous tumours of the pancreas. Br J Surg 90:1244–1249PubMedCrossRef

26.

Goh BK, Tan YM, Chung YF et al (2006) A review of mucinous cystic neoplasms of the pancreas defined by ovarian type stroma: clinicopathological featues of 344 patients. World J Surg 30:2236–2245PubMedCrossRef

27.

Balci NC, Semelka RC (2001) Radiological features of cystic, endocrine and other pancreatic neoplasms. Eur J Radiol 38:113–119PubMedCrossRef

28.

Beutow PC, Rao P, Thompson LD (1998) From the archives of the AFIP. Mucinous cystic neoplasms of the pancreas: radiological pathological correlation. Radiographics 18:433–449

29.

Kosmahl M, Pauser U, Peters K et al (2004) Cystic neoplasms of the pancreas and tumour like lesions with cystic features: a review of 418 cases and a classification proposal. Virchows Arch 445:168–178PubMedCrossRef

30.

Goh BK, Tan YM, Chung YF et al (2006) Nonneoplastic cystic and cystic like lesions of the pancreas: may mimic pancreatic cystic neoplasms. ANZ J Surg 76:325–331PubMedCrossRef

31.

Goh BK, Tan YM, Thng CH et al (2008) How useful are clinical, biochemical and cross-sectional imaging features in predicting potentially malignant or malignant cystic lesions of the pancreas? Results from a single institution experience with 220 surgically treated patients. J Am Coll Surg 206:17–27PubMedCrossRef

32.

Friedrich CA (1999) Von Hippel-Lindau syndrome: a pleomorphic condition. Cancer 86(11 Suppl):2478–2482PubMedCrossRef

33.

Sperti C, Pasquali C, Guolo P et al (1996) Serum tumor markers and cyst fluid analysis are useful for the diagnosis of pancreatic cystic tumors. Cancer 78:237–243PubMedCrossRef

34.

Bassi C, Salvia R, Gumbs AA et al (2002) The value in standard serum tumour markers in differentiating mucinous from serous cystic tumours of pancreas: CEA, CA19–9, CA125, CA15–3. Langenbech Arch Surg 387:281–285CrossRef

35.

Fernandez-del Castillo C, Alsfasser G, Targarona J et al (2006) Serum CA19–9 in the management of cystic lesions of the pancreas. Pancreas 32:220PubMed

36.

Ramage JK, Davies AHG, Ardill J et al (2005) Guidelines for the management of gastroenteropancreatic neuroendocrine tumours. Gut 54:1–16CrossRef

37.

Handrich SJ, Hough DM, Fletcher JG et al (2005) The natural history of the incidentally discovered small simple pancreatic cyst: long-term follow-up and clinical implications. AJR Am J Roentgenol 184:20–23PubMed

38.

Brugge WR, Lewandrowski K, Lee-Lewandrowski et al (2004) Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 126:1330–1336PubMedCrossRef

39.

van der Waaij LA, van Dulleman HM, Porte RJ (2005) Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc 62:380–391

40.

Linder JD, Greenen JF, Catalano MF (2006) Cyst fluid analysis obtained by EUS guided FNA in the evaluation of discrete cystic neoplasms of the pancreas: a prospective single-centre experience. Gastrointest Endosc 64:692–702CrossRef

41.

Sperti C, Pasquali C, Chierichetti F et al (2001) Value of 18-flurodeoxyglucose positron emission tomography in the management of patients with cystic tumours of the pancreas. Ann Surg 234:675–680PubMedCrossRef

42.

Sperti C, Pasquali C, Decet G et al (2005) 18-Flurodeoxyglucose positron emission tomography in differentiating malignant from benign pancreatic cyst: a prospective study. J Gastrointest Surg 9:22–29PubMedCrossRef

43.

Goh BKP, Tan YM, Chung YA et al (2007) Pancreatic cysts: a proposed management algorithm based on current evidence. Am J Surg 193:749–755PubMedCrossRef

44.

Lee CJ, Scheiman J, Anderson MA et al (2008) Risk of malignancy in resected cystic tumors of the pancreas ≤3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report. J Gastrointest Surg 12:234–242PubMedCrossRef

45.

Lahav M, Maor Y, Avidan B et al (2007) Nonsurgical management of asymptomatic incidental pancreatic cysts. Clin Gastroenterol Hepatol 5:813–817PubMedCrossRef

46.

Pelaez-Luna M, Chari ST, Smyrk TC et al (2007) Do consensus indications for resection in branch duct intraductal papillary mucinous neoplasms predict malignancy? A study of 147 patients. Am J Gastroenterol 102:1759–1764PubMedCrossRef

47.

Aljarabah M, Ammori BJ (2007) Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series. Surg Endosc 21:1936–1944PubMedCrossRef

48.

Nealon WH, Walser E (2003) Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis. Ann Surg 237:614–620PubMedCrossRef

49.

Fujino Y, Suzuki Y, Yoshikawa T et al (2006) Outcomes of surgery for IPMN of the pancreas. World J Surg 30:1909–1914PubMedCrossRef

50.

Crippa S, Bassi C, Warshaw AL et al (2007) Middle pancreatectomy: indications, short- and long-term operative outcomes. Ann Surg 246:69–76PubMedCrossRef

Title: Incidental Pancreatic Cystic Lesions
Authors: Senarath Edirimanne
Saxon J. Connor
Publication date: 01-09-2008
Publisher: Springer-Verlag
Published in: World Journal of Surgery / Issue 9/2008
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-008-9633-6

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Incidental Pancreatic Cystic Lesions

Abstract

Introduction

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

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