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Pancreatic Cyst Disease A Review

Alexander Stark, MD1; Timothy R. Donahue, MD1; Howard A. Reber, MD1; O. Joe Hines, MD1
[+] Author Affiliations
1Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
JAMA. 2016;315(17):1882-1893. doi:10.1001/jama.2016.4690.
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Importance  Cystic lesions of the pancreas are common and increasingly detected in the primary care setting. Some patients have a low risk for developing a malignancy and others have a high risk and need further testing and interventions.

Observations  Pancreatic cysts may be intraductal mucinous neoplasms, mucinous cystic neoplasms, serous cystadenomas, solid pseudopapillary neoplasms, cystic variations of pancreatic neuroendocrine tumors, pancreatic ductal adenocarcinomas, or 1 of several types of nonneoplastic cysts. Mucinous (intraductal mucinous neoplasm or mucinous cystic neoplasm) lesions have malignant potential and should be distinguished from serous lesions (serous cystadenomas) that are nearly always benign. Symptomatic patients or those having high-risk features on initial imaging (eg, main pancreatic duct dilatation, a solid component, or mural nodule) require further evaluation with advanced imaging, possibly followed by surgical resection. Advanced imaging includes endoscopic ultrasound with cyst fluid analysis and cytology to confirm the type of cyst and determine the risk of malignancy. Small cysts (size <3 cm) in asymptomatic patients without any suspicious features may be observed with serial imaging because the risk for malignancy is low.

Conclusions and Relevance  The management of pancreatic cysts requires risk stratification for malignant potential based on the presence or absence of symptoms and high-risk features on cross-sectional imaging. Because pancreatic cysts are becoming more frequently diagnosed, clinicians should have a systematic approach for establishing a diagnosis and determining which patients require treatment.

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Figure 1.
Examples of Pancreatic Cysts Associated With High Risk for Malignancy

A, Large pancreatic cyst in the head of the pancreas with enhancing solid components (arrowheads). After resection, pathology confirmed an adenocarcinoma arising in a main duct intraductal papillary mucinous neoplasm (IPMN). B, Large cyst involving the main pancreatic duct with associated nodule (arrowhead) and distal main pancreatic duct dilation greater than 10 mm. Pathology subsequently confirmed ductal adenocarcinoma arising in a main duct IPMN. C, Distal main pancreatic duct dilation greater than 10 mm, suggestive of main duct IPMN, with a distal solid soft tissue mass (arrowhead). After distal pancreatectomy and splenectomy, main duct IPMN with high-grade dysplasia was confirmed along with invasive mucinous adenocarcinoma. D, Classic computed tomographic appearance of a mucinous cystic neoplasm showing a large unilocular cyst in the body and tail of the pancreas. This large, 10.2-cm cyst arising from the distal pancreas did not involve the pancreatic duct. Pathology confirmed mucinous cystic neoplasm. A-C are mid-abdominal axial contrast-enhanced computed tomographic scans; D, coronal contrast-enhanced computed tomographic scan.

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Figure 2.
Differentiating Oligocystic Serous Cystadenoma From Mucinous Cystic Neoplasm

Mid-abdominal axial contrast-enhanced computed tomographic image of an oligocystic lesion pathologically confirmed as serous cystadenoma after resection (panel A) and of a septated lesion confirmed as mucinous cystic neoplasm after resection (panel B). To differentiate these 2 lesions, workup with endoscopic ultrasound and cyst fluid analysis is required.

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Figure 3.
Examples of Pancreatic Cysts Associated With Low Risk for Malignancy

A, Mid-abdominal axial contrast-enhanced axial computed tomographic image. Classic computed tomographic appearance of microcystic serous cystadenoma with innumerable septations and a central stellate scar. B, Oblique coronal abdominal magnetic resonance cholangiopancreatography demonstrating multifocal branch duct intraductal papillary mucinous neoplasm. The caliber of the main pancreatic duct is normal throughout the pancreas. No single lesion measures greater than 1.5 cm in diameter.

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Figure 4.
Proposed Strategy for the Evaluation and Management of a Pancreatic Cyst

BD-IPMN indicates branch duct intraductal papillary mucinous neoplasm; CEA, carcinoembryonic antigen; CT, computed tomography; EUS-FNA, endoscopic ultrasound–guided fine needle aspiration; IPMN, intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; MD-IPMN, main duct intraductal papillary mucinous neoplasm; MPD, main pancreatic duct; MRI, magnetic resonance imaging; SCA, serous cystadenoma.

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