At any health care facility, patients who present with abdominal pain are frequently given x-rays, ultrasounds, CT scans, and MRIs for the purposes of diagnosing their condition. This, however, can eventually lead to more invasive diagnostic procedures such as an endoscopic ultrasound or endoscopic retrograde cholangiopancreatography.
As a result of the increased use of abdominal imaging, previously undetected, under-reported lesions such as pancreatic cysts may be found. After additional work-up, the pancreatic cyst may not be the true cause of the patient’s abdominal symptoms, but rather, represents an incidental finding. However, this may cause a diagnostic dilemma for the health care provider—how do they proceed with the work-up of a pancreatic cyst so as not to miss a potentially life-threatening malignancy in the future?
Pancreatic cysts can be incidental findings in up to 2% of patients undergoing CT or MRI of the abdomen.1 These cysts can be classified as either non-neoplastic or neoplastic; the latter representing 50% of pancreatic cysts and includes intraductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms, serous cystic tumors, and solid pseudopapillary neoplasms.2 In general, surgery is the first-line treatment for these lesions with malignant potential, although there is some controversy about how to best manage different subtypes of IPMNs.3
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A recent study by Wu and colleagues retrospectively reviewed over 1,700 patients with neoplastic pancreatic cysts. 4 Approximately 3% of these patients had malignant cysts, and 75% of these malignant cysts were diagnosed within 3 months of initial cyst detection. During a 2-year surveillance period, there was a malignancy incidence of 0.4% per year. When adjusted for age and gender, the overall risk of pancreatic malignancy was 35 times higher compared with the general population. Calcification, main pancreatic ductal dilation, lack of septations, and larger cyst size were all associated with an increased risk of malignancy.
Neoplastic pancreatic cysts will continue to be incidental findings from abdominal imaging; therefore, health care practitioners should be cognizant of the basic diagnostic work-up as well as the appropriate follow-up plan. Although these cysts may not actually contribute to a patient’s symptoms at the time of their presentation, the findings should not be ignored because of the malignant potential seen in certain subtypes of cysts.
More structured guidelines are needed in the future to further characterize the diagnostic work-up of neoplastic pancreatic cysts, which cannot be managed solely based on imaging results. However, radiologic studies should continue to be useful tools in the early risk-stratification of these patients.
References
- de Jong K, Nio CY, Hermans JJ, et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol. 2010;8(9):806-811.
- Fernandez-del Castillo C, Targarona J, Thayer SP, et al. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg. 2003;138(4):427.
- Khalid A, Brugge W. ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts. Am J Gastroenterol. 2007;102(10):2339.
- Wu BU, Sampath K, Berberian CE, et al. Prediction of malignancy in cystic neoplasms of the pancreas: a population-based cohort study. Am J Gastroenterol 2014;109(1):121-129.
