Updates in diagnosis and management of pancreatic cysts

Table 1 Key Features of pancreatic cyst guidelines

Specifics of Guidelines	2015 AGA	2017 Fukuoka	2017 ACG	2017 ACR	2018 European Study Group
Patient population	Incidental pancreatic cysts	Suspected MCN and IPMN	All pancreatic cysts	Incidental pancreatic cysts	All pancreatic cysts
Threshold for EUS and/or surgery	At least 2 risk factors	1 risk factor	1 risk factor	1 risk factor	1 risk factor
Surveillance recommendations in unresected cysts	MRI in 1 year, then every 2 yr	Surveillance based on cyst size	Surveillance based on cyst size	Surveillance based on cyst size and age	Surveillance based on cyst size and diagnosis
Stopping surveillance	(1) After 5 yr of stability without development of high-risk features; (2) Surgically unfit; and (3) Select resected cysts including BD-IPMN with no, low or moderate-grade dysplasia	(1) Surgically unfit; and (2) Following resection of serous cystadenoma and MCN without invasive cancer	(1) Surgically unfit; (2) Following resection of serous cystadenoma and MCN without invasive cancer; and (3) Individualize approach to patients > 75	(1) 9-10 yr and stop at age 80; and (2) For cysts discovered > age 80, limited surveillance for 4 yr only if stable	Surgically unfit

AGA: American Gastroenterological Association; ACG: American College of Gastroenterology; EUS: Endoscopic ultrasound; MRI: Magnetic resonance imaging; MCN: Mucinous cystic neoplasm; IPMN: Intraductal papillary mucinous neoplasm; BD-IPMN: Branch duct-intraductal papillary mucinous neoplasm.

Table 2 Cyst fluid studies

Cyst fluid test	Test characteristics	Diagnosis
String sign ≥ 1 cm, ≥ 1 s	95% specificity, 94% positive predictive value	Mucinous
Cyst fluid cytology	63% sensitivity	-
Cyst wall cytology	29% increased diagnostic yield	-
CEA > 192 ng/mL	75% sensitivity, 84% specificity	Mucinous
CEA < 5 ng/mL	50% sensitivity, 95% specificity	Serous cystadenoma, pseudocyst, cystic neuroendocrine tumor
Amylase < 250 U/L	44% sensitivity, 98% specificity	Excludes pseudocyst
Glucose < 50 mg/dL	89% sensitivity, 78% specificity	Mucinous
KRAS/GNAS mutation	89% sensitivity, 100% specificity	Mucinous

CEA: Carcinoembryonic antigen.

Table 3 Surveillance recommendations from pancreatic cyst guidelines

2015 AGA	2017 Fukuoka	2017 ACG	2017 ACR	2018 European Study Group
Repeat 1 yr then q2 years until 5 yr	< 1 cm: q2-3 years	< 1 cm: q2 years x4 years	< 1.5 cm + < 65-year-old: q1 year x5, q2 years x2	< 1.5 cm: q1 year x3 years then q2 years
	1-2 cm: q1 year x2 years	1-2 cm: q1 year x3 years then q2 years x4 years	< 1.5 cm + ≥ 65-year-old: q2 years x5	≥ 1.5 cm: q6 mo x2 then q1 year
	2-3 cm: EUS in 3-6 mo then increase interval and alternate with MRI	2-3 cm: MRI/EUS q6-12 mo x3 years then q1 year x4 years	1.5-1.9 cm connected to MPD: q1 year x5 then q2 years x2	IPMN or MCN: q6 mo x2 then q1 year
	> 3 cm: MRI alternate with EUS q3-6 mo	> 3 cm: Consider referral to multidisciplinary pancreas group; MRI/EUS q6 mo x3 years, then MRI/EUS q1 year x4 years	2-2.5 cm connected to MPD or 1.5-2.5 cm without MPD connection or > 2.5 cm: q6 mo x4 then q1 year x2 then q2 years x3

AGA: American Gastroenterological Association; ACG: American College of Gastroenterology; EUS: Endoscopic ultrasound; MRI: Magnetic resonance imaging; MCN: Mucinous cystic neoplasm; IPMN: Intraductal papillary mucinous neoplasm; MPD: Main pancreatic duct.