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©The Author(s) 2020.
World J Gastroenterol. Mar 21, 2020; 26(11): 1128-1141
Published online Mar 21, 2020. doi: 10.3748/wjg.v26.i11.1128
Published online Mar 21, 2020. doi: 10.3748/wjg.v26.i11.1128
Table 1 Pathological classification of most common pancreatic cysts
Inflammatory fluid collections |
Acute peripancreatic fluid collections |
Pseudocysts |
Acute necrotic collections |
Walled-off pancreatic necrosis |
Non-neoplastic |
True cysts |
Mucinous non-neoplastic cysts |
Lymphoepithelial cysts |
Pancreatic cystic neoplasms |
Serous cystic neoplasms |
Mucinous cystic neoplasm |
Intrapapillary mucinous neoplasm |
Solid papillary neoplasm |
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 |
Table 3 Cyst fluid analysis
Cyst fluid analysis | |
European guidelines[28] | Cyst fluid CEA with cytology, or KRAS/GNAS mutation analysis for differentiating IPMN or MCN from other pancreatic cysts |
American College of Gastroenterology (ACG) guidelines[30] | Cyst fluid CEA to differentiate IPMNs and MCNs from other cyst types |
Cyst fluid cytology to assess for HGD or pancreatic cancer when imaging features are alone insufficient for surgery | |
Molecular markers like KRAS or GNAS mutations can help identify IPMNs or MCNs when the diagnosis is not clear | |
American Gastroenterology Association (AGA) guidelines[31] | Cyst fluid cytology is recommended for the evaluation of high-risk features on imaging. The role of molecular markers is not clear and further research is needed |
Revised IAP 2017 guidelines[32] | Cyst fluid CEA can distinguish mucinous from non-mucinous cysts. CEA level ≥ 192-200 ng/mL is 80% accurate for the diagnosis of mucinous cyst[38,45] |
Cyst fluid cytology can be diagnostic but sometimes limited by scant cellularity[43,44] | |
Cyst fluid amylase can differentiate benign from malignant MCN and amylase levels are higher in pseudocysts than non-pseudocysts[45]. The role of molecular markers like KRAS and GNAS mutations is still evolving | |
American College of Radiology guidelines[33] | Cyst fluid CEA ≥ 192 ng/mL can help identify a mucinous cyst[46] |
Cyst fluid amylase > 250 IU/L suggests pseudocyst[11] | |
KRAS and GNAS molecular markers can help differentiate mucinous from non-mucinous cysts[47] | |
Cyst cytology can identify dysplastic cells |
Table 4 Endoscopic ultrasound-fine needle aspiration indications
Endoscopic ultrasound-Fine needle aspiration indications | |
European guidelines[28] | Differentiating mucinous vs non-mucinous |
Malignant vs benign | |
CT or MRI unclear | |
Only when results are expected to change clinical management | |
American College of Gastroenterology guidelines[30] | Jaundice |
Acute pancreatitis | |
Significantly elevated serum CA 19-9 | |
Mural nodule | |
A solid component within cyst or pancreatic parenchyma | |
Dilation of MPD ≥ 5 mm | |
Focal dilation of PD | |
Cyst size > 3 cm | |
When the diagnosis of cysts is unclear or results will likely alter management | |
Cyst fluid CEA to differentiate IPMNs and MCNs from other cyst types | |
New onset or worsening diabetes | |
Increase in cyst size > 3 mm/yr | |
American Gastroenterology Association guidelines[31] | At least 2 high-risk features |
Cyst size ≥ 3 cm | |
Dilated MPD | |
Solid component | |
Revised IAP 2017 or revised Fukuoka guidelines[32] | Pancreatitis |
Cyst ≥ 3 cm | |
Enhancing mural nodule < 5 mm | |
Thickened/enhancing cyst wall | |
Main duct size 5-9 mm | |
An abrupt change in caliber of the pancreatic duct with distal pancreatic atrophy | |
Lymphadenopathy | |
Increased serum level of CA19-9 | |
Cyst growth rate ≥ 5 mm/2 yr | |
American College of Radiology guidelines[33] | Mural nodule |
Wall thickening | |
Dilation of MPD ≥ 7 mm | |
Extrahepatic biliary obstruction/Jaundice |
Table 5 Indications of surgery for pancreatic cysts
Absolute indications of surgery | Relative indications of surgery | |
European guidelines[28] | Intraductal papillary mucinous neoplasm: Cytology positive for malignancy/High-grade dysplasia; Solid mass; Jaundice; Mural nodule ≥ 5 mm; Main pancreatic duct dilation > 10 mm | Cyst growth rate > 5 mm/yr |
Mucinous cystic neoplasm: Size ≥ 4 cm | Serum CA 19-9 > 37 U/mL | |
Symptomatic Mural nodule | MPD dilation 5-9 mm | |
Cyst diameter ≥ 40 mm | ||
New-onset diabetes mellitus | ||
Acute pancreatitis related to IPMN | ||
Mural nodule < 5 mm | ||
American College of Gastroenterology guidelines[30] | Intraductal papillary mucinous neoplasm or Mucinous cystic neoplasm: | N/A |
Referral to EUS-FNA/Multidisciplinary; team: | ||
Jaundice | ||
Acute pancreatitis | ||
Significantly elevated CA 19-9 | ||
Mural nodule | ||
A solid component in cyst/pancreatic parenchyma | ||
MPD > 5 mm | ||
Focal dilation of PD or MD-IPMN | ||
HGD/Pancreatic cancer on cytology | ||
American Gastroenterology Association guidelines[31] | Pancreatic cysts: | N/A |
EUS-FNA cytology positive for - | ||
HGD/cancer | ||
Both solid component and dilated PD on MRI and EUS | ||
Revised IAP 2017 or revised Fukuoka guidelines[32] | Obstructive jaundice with pancreatic head cyst | Pancreatitis |
Enhancing mural nodule ≥ 5 mm | Enhancing mural nodule < 5 mm | |
MPD ≥ 10 mm | Thickened/enhancing cyst wall | |
Main duct size 5-9 mm | ||
An abrupt change in caliber of the pancreatic duct with distal pancreatic atrophy | ||
Lymphadenopathy | ||
Increase in serum level of CA 19-9 | ||
Cyst growth rate ≥ 5 mm/2 yr | ||
American College of Radiology guideline[33] | Obstructive jaundice with a cyst in the head of the pancreas | Cyst ≥ 3 cm |
Enhancing solid component within a cyst | Thickened/enhancing cyst wall | |
MPD > 10 mm in the absence of obstruction | Non-enhancing mural nodule | |
MPD ≥ 7 mm |
- Citation: Lanke G, Lee JH. Similarities and differences in guidelines for the management of pancreatic cysts. World J Gastroenterol 2020; 26(11): 1128-1141
- URL: https://www.wjgnet.com/1007-9327/full/v26/i11/1128.htm
- DOI: https://dx.doi.org/10.3748/wjg.v26.i11.1128