Similarities and differences in guidelines for the management of pancreatic cysts

Table 2 Surveillance of pancreatic cysts

	Surveillance of pancreatic cysts
European guidelines[28]	Mucinous cystic neoplasm: Cyst size < 4 cm without symptoms or mural nodules should undergo surveillance every 6 mo for the 1st year using EUS/MRI or both[29]. Followed by annually, if no changes. Lifelong surveillance if they are fit for surgery
	Intraductal papillary mucinous neoplasm (IPMN): Every 6 mo for cysts less than 4cm or low-grade dysplasia for the 1st year with CA 19-9, EUS/MRI or both. Followed by yearly, until no longer fit for surgery
	After surgical resection, HGD or MD-IPMN should have imaging every 6 mo for the 1st 2 yr. Followed by yearly surveillance. Lifelong surveillance if they are fit for surgery
American College of Gastroenterology (ACG) guidelines[30]	Intraductal papillary mucinous neoplasm/Mucinous cystic neoplasm (IPMN/MCN): Cyst size < 1 cm: MRI every 2 yr × 4 yr. If stable in size, consider prolonging the time interval. Any increase in size, consider EUS-FNA in 6 mo and reevaluate
	Cyst size 1-2 cm: MRI every 1 yr × 3 yr. If stable, consider MRI every 2 yr × 4 yr. Once stable, consider prolonging the interval
	Cyst size 2-3 cm: MRI/EUS every 6-12 mo for 3 yr. If stable, MRI every 1-year × 4 yr. Once stable, consider prolonging the interval. Any increase in cyst size should be referred to the multidisciplinary group and consider EUS-FNA
	Cyst size > 3 cm: Referral to the multidisciplinary team. MRI alternating with EUS every 6 mo for 3 yr. Once stable in size, MRI alternating with EUS every year for 4 yr. Once stable in size, consider prolonging the interval
	Stop surveillance when a patient is no longer a surgical candidate or after surgical resection of MCN if no invasive cancer
	The risk of recurrence of IPMN after surgery varies based on the degree of dysplasia
	EUS/MRI every 6 mo after surgical resection of IPMN with HGD
	MRI every 2 yr after surgical resection of IPMN with low to intermediate grade dysplasia in the absence of pancreatic cysts in the remnant pancreas. However, if IPMN or pancreatic cysts are present in the remnant pancreas, then surveillance should be based on cyst size
American Gastroenterology Association (AGA) guidelines[31]	Cyst size < 3 cm without a solid component or PD dilation recommend MRI in 1 yr, followed by every 2 yr for 5 yr.
	Recommend stopping surveillance if no change in cyst characteristics after 5 yr or not a surgical candidate
Revised IAP 2017 or revised Fukuoka guidelines[32]	Branch duct-Intraductal papillary mucinous neoplasm (BD-IPMN): Cysts without high-risk stigmata should undergo CT/MRI every 3-6 mo to establish stability if prior imaging is not available. Subsequently, surveillance should be based on size stratification
	For cyst size < 1 cm, CT/MRI every 2 yr
	For cyst size 1-2 cm, CT/MRI every 6 mo for a year, followed by every year for 2 yr and prolong the interval if stable
	For cyst size 2-3 cm, EUS in 3-6 mo for 1 year. Increase the interval to 1 yr with EUS/MRI as appropriate. Consider surgery in young patients with a need for prolonged surveillance
	For cyst size > 3 cm, close surveillance alternating MRI with EUS every 3-6 mo. Strongly recommend surgery in young patients
	In surgically resected IPMN, surveillance is recommended with cross-sectional imaging twice a year for patients with a family history of pancreatic ductal adenocarcinoma, surgical margin positive for HGD and non-intestinal sub-type of IPMN. For all others, every 6-12 mo of cross-sectional imaging is recommended
American College of Radiology (ACR) guidelines[33]	Cyst size < 1.5 cm and age < 65 yr: CT/MRI every year for 5 yr, followed by every 2 yr for 4 yr. Stop surveillance if stable over 9 yr
	Cyst size < 1.5 cm and age 65-79 yr: CT/MRI every 2 yr for a total of 10 yr. Stop surveillance if the cyst is stable for 10 yr
	If there is interval change and cyst size < 1.5 cm, consider CT/MRI every year or EUS-FNA. EUS-FNA shows a mucinous cyst or indeterminate cyst, CT/MRI every 6 mo for 2 yr, followed by every year for 2 yr and every 2 yr for 6 yr. Stop surveillance if the cyst is stable after 10 yr
	Any further interval growth of cyst should be referred to surgery for further evaluation
	Cyst size 1.5-1.9 cm with MPD communication: CT/MRI every year for 5 yr, followed by every 2 yr for 4 yr. Stop surveillance if cyst size stable for over 9 yr
	Cyst size 2-2.5 cm with MPD communication: CT/MRI every 6 mo for 2 yr, followed by every year for 2 yr and subsequently every 2 yr for 6 yr. Stop surveillance if cyst size is stable for 10 yr
	If there is interval change and cyst size ≤ 2.5 cm, CT/MRI every 6 mo for 2 yr, followed by every year for 2 yr and subsequently every 2 yr. If cyst size > 2.5 cm, consider EUS-FNA
	If EUS-FNA shows a mucinous cyst or indeterminate cyst, CT/MRI every 6 mo for 2 yr, followed by every year for 2 yr and every 2 yr for 6 yr
	EUS-FNA is recommended for any mural nodule, wall thickening, dilation of MPD ≥ 7 mm or extrahepatic biliary obstruction/Jaundice irrespective of cyst size
	Cyst size 1.5-2.5 cm without MPD communication or cannot be determined: CT or MRI every 6 mo for 2 yr, followed by every year for 2 yr and subsequently every 2 yr for 6 yr. Stop surveillance if cyst size is stable after 10 yr
	If there is interval change and cyst size < 2.5 cm, consider CT/MRI every 6 mo for 1 year, followed by every year for 5 yr and subsequently every 2 yr. If cyst size is > 2.5 cm, consider EUS-FNA
	Cyst size >2.5 cm: If a cyst is a low risk by imaging, consider CT/MRI every 6 mo for 2 yr. If stable after 2 yr, CT/MRI every yr for 2 yr and subsequently every 2 yr for 6 yr. Stop surveillance if stable in cyst size
	Any interval changes in cyst size, consider EUS-FNA. Any high-risk stigmata like jaundice, enhancing mural nodule, wall thickening and MPD ≥ 10 mm refer to surgery for evaluation
	Age ≥ 80 yr with cyst size ≤ 2.5 cm: CT/MRI every 2 yr for 4 yr. Stop surveillance if cyst size is stable in size: If there is interval change and cyst size ≤ 2.5 cm, consider CT/MRI every year. Stop surveillance if the cyst stabilizes or not a surgical candidate; If there is interval change and cyst size > 2.5 cm, consider EUS-FNA
	Age ≥ 80 yer with cyst size ≥ 2.5 cm: If low risk by imaging, consider CT/MRI every 2 yr for 4 yr. Stop surveillance if cyst size is stable; If there is interval change in cyst size, consider EUS-FNA
	High risk (mural nodule, wall thickening, dilation of MPD ≥ 7 mm or extrahepatic biliary obstruction/Jaundice) features by imaging should be referred to EUS-FNA
	High-risk stigmata (jaundice, enhancing mural nodule, wall thickening, and MPD ≥ 10 mm) by EUS or imaging refer to surgery for evaluation

MCN: Mucinous cystic neoplasm; EUS-FNA: Endoscopic ultrasound-Fine needle aspiration; MRI: Magnetic resonance imaging; IPMN: Intraductal papillary mucinous neoplasm; HGD: High-grade dysplasia; MD-IPMN: Main duct-Intraductal papillary mucinous neoplasm; PD: Pancreatic duct; MPD: Main pancreatic duct.