Diagnosis and management of Asymptomatic Neoplastic Pancreatic cyst.pptx

1. Diagnosis and management of
Asymptomatic Neoplastic
Pancreatic cyst
American Gastroenterological Association Institute Guidelines
Vege et al Gastroenterology Vol. 148, No. 4 2015

2. Vege et al Gastroenterology Vol. 148, No. 4 2015

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4. Recommendation on Surveillance
• When the probability of a cyst becoming malignant is explained to
them, they may elect not to undergo surveillance
• Patients who have a limited life expectancy are unlikely to benefit
• surveillance is inappropriate for patients who are not surgical candidates
because of age or severe comorbidities
Vege et al Gastroenterology Vol. 148, No. 4 2015

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6. Recommendation on Surveillance
• MRI is the preferred surveillance imaging modality over computed
tomography
• No radiation hazards
• better demonstrates the structural relationship between the pancreatic duct
and associated cyst
• less invasive than EUS
The follow-up interval of 1 and then 2 years is not based on any evidence but is
believed to be reasonable given the small absolute risk of malignancy
Vege et al Gastroenterology Vol. 148, No. 4 2015

7. size >3 cm increased the risk of malignancy approximately 3 times
the presence of a solid component increased the risk of malignancy
approximately 8 times
EUS FNA sensitivity 60% specificity 90%
Vege et al Gastroenterology Vol. 148, No. 4 2015

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9. Indication of EUS FNA
Vege et al Gastroenterology Vol. 148, No. 4 2015

10. When Can Pancreatic Cyst Surveillance Be
Discontinued?
Vege et al Gastroenterology Vol. 148, No. 4 2015

11. When Can Pancreatic Cyst Surveillance Be
Discontinued?
• risk of malignant transformation of pancreatic cysts is approximately 0.24% per
year
• The risk of cancer in cysts without a significant change over a 5-year period is
likely to be lower
• strong family history of pancreatic cancer or equivocal changes in cysts that
possess high-risk features- extended period surveillance
Vege et al Gastroenterology Vol. 148, No. 4 2015

12. When to Offer Surgery for Pancreatic Cysts
Vege et al Gastroenterology Vol. 148, No. 4 2015

13. When to Offer Surgery for Pancreatic Cysts
• Positive cytology on EUS-guided FNA has the highest specificity for
diagnosing malignancy
• if there is a combination of high-risk features on imaging, then this is
likely to increase the risk of malignancy even further
Vege et al Gastroenterology Vol. 148, No. 4 2015

14. When to Offer Surgery for Pancreatic Cysts
if a cyst has both a solid component and a dilated pancreatic duct
(confirmed on both EUS and MRI), the specificity for malignancy is
likely to be high even in the absence of positive cytology
Vege et al Gastroenterology Vol. 148, No. 4 2015

15. When to Offer Surgery for Pancreatic Cysts
• Surgery is likely to be most beneficial in cases of cyst resection for
HGD, thereby preventing malignancy
• approximately 17% of patients with IPMNs undergoing pancreatic
resection have cysts that harbor HGD
Vege et al Gastroenterology Vol. 148, No. 4 2015

16. Surveillance After Surgery
Vege et al Gastroenterology Vol. 148, No. 4 2015

17. Surveillance After Surgery
Vege et al Gastroenterology Vol. 148, No. 4 2015

22. • Thank you