Pancreatic cystic neoplasms (PCN)

Pancreatic cystic neoplasms (PCN) are estimated to be present in 2- 45% of the general population (1,2)

• PCN comprise a clinically challenging entity as their biological behaviour ranges from benign to malignant disease - often difficult to differentiate between the various types of PCN.

Recommendations include conservative management, relative and absolute indications for surgery

• a conservative approach is recommended for asymptomatic MCN (mucinous cystic neoplasm) and IPMN ( intraductal papillary mucinous neoplasm) measuring <40 mm without an enhancing nodule (1)
  • relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter>=40 mm
    • absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm
    • lifelong follow-up of IPMN is recommended in patients who are fit for surgery
      
      
  • MCN measuring <40mm without a mural nodule or symptoms may undergo surveillance with MRI, EUS, or a combination of both
    • for patients with MCN measuring between 30 and 40mm, clinicians can incorporate other factors such as age, comorbidities, patient's surgical risk, and patient preference (1)
      
      
  • serous cystic neoplasm (SCN)
    • SCN is a benign entity
      • there are essentially no deaths that are attributable to dissemination/malignant behaviour of an SCN
      • surgical intervention
        • surgery is recommended only in patients with symptoms related to the compression of adjacent organs (ie, bile duct, stomach, duodenum, portal vein)
        • size of about 60% of SCN remains stable - an increase in cyst size is seen in 40% but the rate of growth is slow and new onset of symptoms is very rare (2)

Reference:

• European evidence-based guidelines on pancreatic cystic neoplasms.Gut. 2018 May;67(5):789-804
• Ip IK et al. Focal cystic pancreatic lesions: assessing variation in radiologists' management recommendations. Radiology 2011;259:136-41.
• Reid MD et al. Serous neoplasms of the pancreas: a clinicopathologic analysis of 193 cases and literature review with new insights on macrocystic and solid variants and critical reappraisal of so-called "serous cystadenocarcinoma". Am J Surg Pathol 2015;39:1597-610.