Risk Assessment of Pancreatic Cysts: Benign and Malign Entwined

Excerpt

The widespread availability of high-resolution cross-sectional imaging has increased the discovery rate for pancreatic cystic lesions (PCLs), a challenging entity. PCLs encompass a spectrum ranging from benign lesions to malignant disease. Though the awareness of possible malignant potential has historically led to surgical resection for their treatment, pancreatic surgery, despite recent advances, still carries significant morbidity. Therefore, the management of PCLs has transitioned toward a more selective approach with the aim of avoiding costly life-long surveillance or unnecessary burdensome surgery for benign cysts while considering appropriate surveillance for low-risk lesions and surgical treatment for cysts at high risk of current or future malignancy. Nevertheless, all diagnostic tests routinely available in clinical practice underperform in regard to differentiating benign to potentially malignant cystic tumors and to detecting high-grade dysplasia (HGD) or invasive cancer in PCLs. Several scientific societies developed clinical guidelines in order to assist physicians in the decision-making process. Guidelines from the American College of Gastroenterology (ACG), the European Study Group on Pancreatic Cysts, and the updated guidelines from the International Association of Pancreas (IAP) are the most recent and widely used [1‐3]. All of these recommendations use a combination of symptoms, morphological features, and high-risk cytological features of the fine-needle aspirate in order to predict risk. Nonetheless, these guidelines are mostly based on expert opinion and supported by low-quality evidence. Every step toward improved risk stratification assessing the accuracy of established risk factors and investigating new markers represents a significant advance in the clinical management of pancreatic cysts. …