EUS provides essential information for diagnosing and managing pancreatic cystic lesions (PCLs): (1) EUS with fine-needle aspiration and cyst fluid analysis is more sensitive than CT or MRI at differentiating neoplastic and non-neoplastic cysts. (2) EUS can detect mural nodules and assess vascularity in cysts and septa, aiding diagnosis. New tools like contrast-enhanced EUS and molecular analysis further improve diagnosis. (3) While guidelines recommend consideration of EUS for PCL diagnosis, EUS-guided therapy is only advised in trials due to the need for more evidence. Management depends on accurate risk stratification using

1. EUS in Pancreatic Cystic Lesions
Dr. D. Viswanath Reddy,
M.D., D.M., PDF(Advanced Endoscopy),
ESEGH(MRCP), Diploma in EUS(WISE),
Consultant Gastroenterologist,
Yashoda Hospital.

2. Synopsis
• PCLs – Magnitude, Types
• Challenge: Benign or Malignant!, Surgery?
• Radiology
• EUS-Diagnosis of PCLs
• Newer tools
• EUS in Therapy of PCLs
• Case snippets

3. PCLs
• 2–45% of general population(24% Autopsy)
• Reported prevalence 2.1–2.6% for CT & 13.5–45%
for MRI/MRCP.
• Age, Asians, Pancreatitis, Family history....
• Incidental, Asym., benign malignant.
• Earlier 40% resection was of benign, still ~15-20%
• Early detection paramount for early treatment.

4. Pancreatic cystic Lesions-Types

6. • 45 year old ethanol
consumer presented
with acute abdominal
pain 4 weeks back with
SIRS recovered and now
has persistent pain.

7. Pseudocyst
• 20%-49%
• 5th decade
• 7:3 Body/tail > Head/uncinate
• Well-defined
• Peripancreatic fluid collection of homogenously low attenuation

9. Case: 50 year old
female, nonalcoholic,
nonsmoker with pain
abdomen, jaundice or
weight loss. Lap. Chole.
done considering
Biliary Pancreatitis.
Collection considered
as Pseudocyst.
• Well-defined, unilocular/
• Macrolacunae
• Mural Nodule/mass

10. Mucinous Cystadenoma
• 11-18%
• 5th decade
• 1:9 M:F
• Body/tail > head/uncinate
• Well-defined, unilocular/
• Macrolacunae
• Peripheral rim of calcification
• CEA >192; String Sign; Cytology
• High malignant potential

11. Serous cystadenoma
• 13-23%
• 6th decade
• 4:6 M:F
• Head/uncinate = body/tail
• Well-defined
• Small cysts separated by delicate
septa
• Central stellate scar with sunburst
pattern of calcification
• CEA<5; Amylase-low
• Low malignancy potential

13. MD-IPMN
• 21-33%
• 7th decade
• 6:4 M:F
• Head/uncinate > body/tail
• Distended pancreatic duct
• Polypoid intraductal lesion
• Patulous ampulla with mucin
extrusion
• CEA>192; String Sign
• High malignancy potential
60 year old male presented
with pain abdomen s/o Acute
pancreatitis.

14. BD-IPMN

15. SPEN
• 2%
• 3rd decade
• 1:9 M:F
• Body/tail > head/uncinate
• Well-defined
• Heterogeneous-appearing mass with solid and cystic areas
• High malignancy potential

16. Cystic PNET
• 4-7%
• 6th decade
• 5:5 M:F
• Body/tail > Head/uncinate
• Well-defined
• Heterogeneous-appearing mass
• with solid and cystic areas
• Hypervascular cyst rim

17. Cystic Degeneration of
Adenocarcinoma

18. EUS- Mural Nodule vs Mucus Plug
• Mucus – hypoechoic & smooth, hyperechoic rim
• Nodules - iso- or hyperechoic without
hyperechoic rim or smooth edge
• Rotating patient & try move lesion with FNA
needle can help to differentiate mucus vs nodule.
• CH-EUS enhancement in nodule, not if mucus.
• The sensitivity and specificity of EUS (75% and
83%) were superior to CT (24% and 100%) for
nodules, and surpasses diagnostic yield of MRI

19. Current Diagnostic Approach
• History
• Initially- Non-invasive
imaging-CT/MRI
• EUS
– Fluid analysis-
Biomarkers, cytology.
– Biopsy
– Molecular analysis

20. Radiology
• Combining MDCT and MRI, the accuracy of predicting
malignancy of a PCL increased from 61% (CT) to 81%
• Accuracy for identifying the specific type of PCN is between
40% - 95% for MRI/MRCP and between 40% and 81% for CT
• MRI/MRCP is preferable
– Better to evaluate septa, nodules,
– Main duct, branch duct involvement, communication with MPD
and
– Cyst contents/debris; 79%-82% accurate in identifying mucinous
cysts.
• 18-FDG PET/CT had sensitivity of 57–94%, specificity of 65–
97% and accuracy of 94% in benign vs malignant cysts.
European evidence-based guidelines on pancreatic cystic neoplasms; Gut. 2018 May; 67(5): 789–804. 10.1136/gutjnl-2018-
316027
Kadiyala V, Lee LS. Endosonography 24in the diagnosis and management of pancreatic cysts. World J Gastrointest
Endosc 2015; 7(3): 213-223 [PMID: 25789091 DOI: 10.4253/wjge.v7.i3.213]

21. EUS scores over Radiology
• EUS is recommended as an adjunct to other
imaging modalities (GRADE 2C)
• EUS with or without cyst fluid aspirate analysis
more sensitive (76%) than CT or MRI (48% and
34%) differentiating neoplastic vs non-
neoplastic cysts.
Khashab MA et al. Should we do EUS/FNA on patients with pancreatic cysts? The incremental
diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms. Pancreas. 2013;42:717-
721.

22. Glucose level(<50mg%) in PCF is better than CEA(94 vs 85%) for preoperative diagnosis of mucinous cysts.
McCarty T.R., Garg R., Rustagi T. Pancreatic cyst fluid glucose in differentiating mucinous from nonmucinous pancreatic
cysts: A systematic review and meta-analysis. Gastrointest. Endosc. 2021

23. EUS-FNA
• EUS-FNA should only be performed if change
in management expected(GRADE 2C).
• No - if diagnosis is established by imaging, or
where clear indication for surgery (GRADE 2C).
• Relative contraindications-distance of >10 mm
• EUS-FNA for PCN is safe procedure with
relatively low risk (3.4%) of complications.

24. Antibiotic before FNA of PCL?
• One retrospective study of 253 patients found
antibiotic prophylaxis had no effect on risk of
infection (7% vs 9.3%), although conclusive
evidence is lacking.
• Current practice is single shot antibiotic
treatment prior to EUS-FNA of a cystic lesion.

25. Newer tools
• Contrast EUS
– Mural Nodules,
– Assess vascularity in cyst & septa
– Sonazoid>Sonovue
-EUS-FNA of pancreatic cysts sensitivity 54% for mucinous
versus non-mucinous cysts,
- 44% - 78% when more passes from solid component.
- 84.2% sensitivity when CH-EUS-FNA from fluid analysis &
mural nodules.

26. Other tools
• Moray Forceps
– cyst tissue acquisition yield 90%
– 83.7–88.6% sensitivity and 81.8–94.7%
specificity for mucinous PCN
– adverse events was 8.6–9.9%
• Confocal Laser endocytoscopy(nCLE)
• Molecular analysis(NGS): 4mutations:
– KRAS, GNAS, VHL and one other (PIK3CA,
TP53, SMAD4, PTEN, CDKN2A)
• Artificial Intelligence
– Imaging
– EUS
– Fluid analysis

27. Summary-Cystic Lesions

29. EUS guided Therapy for PCLs
• ?Alternative to surgery in poor / reluctant surgical candidates and low-risk
in cases where malignant potential is uncertain.
• Ethanol lavage
• Paclitaxel stabilizes microtubule polymer to inhibit its disassembly &
induce apoptosis.
• RFA
• Cryotherapy
• Benign with no malignant features, 2-4 cm, uni/oligolocular, and no
connection with MPD.
• Post procedure pain, Pancreatitis, intracyst bleed, infection, Peritonitis.
• EUS-guided therapies for IPMNs should not be performed outside trials.

31. Current Guidelines on PCLs

33. Summary
• Increasing prevalence of PCLs recently.
• Accurate diagnosis & risk stratifying paramount.
• Multimodal diagnosis, EUS complementary.
• EUS scores higher with FNA, Biopsy.
• Fluid biomarkers and Molecular testing key
• Newer tools promising.
• F/U- No-surveillance, Surveillance or Surgery.
• Therapeutic role of EUS in PCLs needs evidence.

34. Thank You