Limits...
Prevalence, Diagnosis and Management of Pancreatic Cystic Neoplasms: Current Status and Future Directions.

Farrell JJ - Gut Liver (2015)

Bottom Line: Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy.IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed.Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.

View Article: PubMed Central - PubMed

Affiliation: Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA.

ABSTRACT
Cystic neoplasms of the pancreas are found with increasing prevalence, especially in elderly asymptomatic individuals. Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy. This review discusses the different cystic neoplasms of the pancreas and reports diagnostic strategies based on clinical features and imaging data. Surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines, is also discussed, with special reference to intraductal papillary mucinous neoplasm (IPMN; particularly the branch duct variant), which is the lesion most frequently identified incidentally. IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed. Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.

No MeSH data available.


Related in: MedlinePlus

The Fukuoka guidelines for the management of presumed BD-IPMN and MCN.BD-IPMN, branch-duct intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; CT, computed tomography; MRI, magnetic resonance imaging, EUS, endoscopic ultrasound.
© Copyright Policy
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4562774&req=5

f1-gnl-09-571: The Fukuoka guidelines for the management of presumed BD-IPMN and MCN.BD-IPMN, branch-duct intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; CT, computed tomography; MRI, magnetic resonance imaging, EUS, endoscopic ultrasound.

Mentions: For patients with a definite diagnosis of a BD-IPMN or those with a strong suspicion of a presumed BD-IPMN, the next major challenge is risk-stratification for cancer development, a crucial determinant of either operative or nonoperative (surveillance) management. The original Sendai guidelines published in 2006 suggested that for patients with definite or presumed BD-IPMN, cysts greater than 3 cm, or for cysts less than 3 cm with symptoms, a dilated main pancreatic duct greater than 6 mm, or nodule, surgical resection is indicated.111 The remainder can be managed nonoperatively with routine surveillance. Evaluation of these original Sendai guidelines on retrospectively collected surgical BD-IPMN patients showed a low positive predictive value (PPV) of ~20%, meaning that for every five surgical resections, only one patient had an advanced lesion; and whereas initial studies suggested a high negative predictive value, meaning no cancers are missed, more recent studies have questioned this finding.77,112–116 The personalization of recommendations for surgery for presumed BD-IPMNs needs take into account several additional factors, including age of patient, overall medical condition, operative risk and location of the cyst. It has been suggested that for younger patients (<65 years), a threshold of 2 cm may be used to determine surgical resection due to the cumulative effect of cancer risk during the patients’ lifetime.117 Since a size of BD-IPMN >3 cm is a weaker indicator of malignancy than the presence of mural nodule and positive cytology, BD-IPMN greater than 3 cm without these signs can be observed without immediate resection, particularly in elderly patients.118 A Fukuoka guideline was recently published giving more specific updated recommendations for surgical resection and surveillance (Fig. 1). These newer guideline’s operating characteristics in the clinical setting needs to be further validated prospectively.23


Prevalence, Diagnosis and Management of Pancreatic Cystic Neoplasms: Current Status and Future Directions.

Farrell JJ - Gut Liver (2015)

The Fukuoka guidelines for the management of presumed BD-IPMN and MCN.BD-IPMN, branch-duct intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; CT, computed tomography; MRI, magnetic resonance imaging, EUS, endoscopic ultrasound.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4562774&req=5

f1-gnl-09-571: The Fukuoka guidelines for the management of presumed BD-IPMN and MCN.BD-IPMN, branch-duct intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; CT, computed tomography; MRI, magnetic resonance imaging, EUS, endoscopic ultrasound.
Mentions: For patients with a definite diagnosis of a BD-IPMN or those with a strong suspicion of a presumed BD-IPMN, the next major challenge is risk-stratification for cancer development, a crucial determinant of either operative or nonoperative (surveillance) management. The original Sendai guidelines published in 2006 suggested that for patients with definite or presumed BD-IPMN, cysts greater than 3 cm, or for cysts less than 3 cm with symptoms, a dilated main pancreatic duct greater than 6 mm, or nodule, surgical resection is indicated.111 The remainder can be managed nonoperatively with routine surveillance. Evaluation of these original Sendai guidelines on retrospectively collected surgical BD-IPMN patients showed a low positive predictive value (PPV) of ~20%, meaning that for every five surgical resections, only one patient had an advanced lesion; and whereas initial studies suggested a high negative predictive value, meaning no cancers are missed, more recent studies have questioned this finding.77,112–116 The personalization of recommendations for surgery for presumed BD-IPMNs needs take into account several additional factors, including age of patient, overall medical condition, operative risk and location of the cyst. It has been suggested that for younger patients (<65 years), a threshold of 2 cm may be used to determine surgical resection due to the cumulative effect of cancer risk during the patients’ lifetime.117 Since a size of BD-IPMN >3 cm is a weaker indicator of malignancy than the presence of mural nodule and positive cytology, BD-IPMN greater than 3 cm without these signs can be observed without immediate resection, particularly in elderly patients.118 A Fukuoka guideline was recently published giving more specific updated recommendations for surgical resection and surveillance (Fig. 1). These newer guideline’s operating characteristics in the clinical setting needs to be further validated prospectively.23

Bottom Line: Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy.IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed.Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.

View Article: PubMed Central - PubMed

Affiliation: Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA.

ABSTRACT
Cystic neoplasms of the pancreas are found with increasing prevalence, especially in elderly asymptomatic individuals. Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy. This review discusses the different cystic neoplasms of the pancreas and reports diagnostic strategies based on clinical features and imaging data. Surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines, is also discussed, with special reference to intraductal papillary mucinous neoplasm (IPMN; particularly the branch duct variant), which is the lesion most frequently identified incidentally. IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed. Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.

No MeSH data available.


Related in: MedlinePlus