The incidence of pancreatic cysts is increasing as imaging becomes more commonplace in clinical care. Being diagnosed with a pancreatic cyst can be scary, however, many cysts are benign and don’t become cancerous. Understanding the different types of pancreatic cysts and how they relate to the risk of pancreatic cancer is vital for establishing a realistic picture of health risks and guiding management protocols.
Choosing the appropriate course of action relies on accurate diagnosis of cyst types. Fortunately, there are many methods for identifying the presence of cysts and determining their type. Misdiagnosis can lead to worse clinical outcomes, where potentially harmful cysts are left untreated, or patients undergo unnecessary and risky surgery to remove a benign cyst. Different pancreatic cysts come with distinct risks and management guidelines.
In this article, we will provide an update on the latest pancreatic cyst guidelines, delving into cyst types, how they are diagnosed, and how they are managed. Our goal is to help demystify the topic of pancreatic cysts and provide a solid resource for our members to understand the complexities of pancreatic cysts and make informed healthcare decisions.
Cysts are sacs made of cells that can form in many areas of the body. They are often fluid-filled but can contain air and solid matter. There are two main categories of pancreatic cysts: mucinous and non-mucinous. The difference here is in the production of mucin, an important protein found in mucus. All mucinous cysts can become malignant, while some non-mucinous cysts cannot. Some cysts cause symptoms like abdominal pain, but many are asymptomatic.
IPMNs are the most common pancreatic cysts. They grow within areas of the pancreas called ducts, which carry digestive fluids from the pancreas to the small intestine. They produce mucin and are fluid-filled. While they have the potential to become cancerous, most IPMNs remain benign. Males are more likely to develop IPMNs, and their incidence increases with age.
MCPNs produce mucin, are generally benign and are found in the body or tail of the pancreas. They are most commonly observed in middle-aged women, with an incidence ratio of 20:1 between women and men. They contain an “ovarian-rich” stroma, a supportive tissue typical of the ovary. This helps them to be distinguished from IPMNs.
These cysts are benign and do not produce mucin. Under the microscope, SCAs have a dense capillary (tiny blood vessel) network and other characteristics that help differentiate them from IPMNs. They can become cancerous, though this is rare.
SPNs are rare low-grade pancreatic tumors that primarily affect young women. SPNs can have both solid and cystic components. They can cause abdominal pain but are often asymptomatic. Surgical removal typically results in a good prognosis.
These tumors begin as solid but can develop a cyst component. They are relatively rare, with an occurrence rate of less than 1:100,000. About 10 percent of PENs occur in individuals with a genetic predisposition. Their neuroendocrine and islet cell characteristics allow them to be differentiated from other cyst types.
These benign cysts typically occur alongside diseases like pancreatitis and are associated with high consumption of alcohol. They do not become cancerous.
Most pancreatic cysts are discovered by chance during scans. This means that their size and shape are often used as a first step in characterizing them in combination with other clinical characteristics. However, the scanning approach is limited because it can’t distinguish between malignant and benign cysts or tell us about cyst type. However, it is essential not to overlook the importance of high-resolution magnetic resonance imaging (MRI) or computed tomography (CT) scans in identifying cysts, which can help catch a disease early while it is still treatable.
EUS-FNA is an invasive procedure that gives a full breakdown of cyst type and other characteristics. Biopsies taken using this method have increased the accuracy of diagnosis. EUS-guided needle-based laser confocal endomicroscopy is a more recent advancement in pancreatic cyst diagnosis.
NGS of biopsy samples is highly effective at distinguishing cyst types and identifying molecular targets for drug treatment. AI is also showing promise in using images to differentiate between cyst types.
Biomarkers found in cyst fluid, such as Carcinoembryonic Antigen (CEA), inflammatory markers, and glucose levels, can help distinguish between cyst types. In combination with other techniques, biomarkers help guide diagnosis and management.
There are many factors to consider when deciding what diagnostic tests to perform and when. Scans are a practical first step for finding cysts. From here, factors such as history of pancreatitis, jaundice, and cyst size influence the choice of further tests.
Ezra provides a comprehensive scanning service that can help identify pancreatic cysts, enabling you to act early and offering you peace of mind.
Most cysts have a low chance of becoming pancreatic tumors. However, monitoring them with scanning and radiological methods is vital for establishing their aggressiveness and determining the need for intervention. Common characteristics used for risk stratification include:
Clinicians use diagnostic information and patient history to determine the best management strategy for pancreatic cysts. Broadly speaking, the choice is between surgical and non-surgical strategies.
In some instances, pancreatic cysts require surgery. Factors affecting decisions for surgery include cyst size, grade, and the patient's age. PENs or SPNs are generally recommended for surgical resection due to their potential to metastasize. IPMNs and MCPNs can also be
recommended for surgical resection if they display signs of invasion or malignant transformation. This is particularly important for MCPNs because they do not recur after resection but carry a greater than 50 percent mortality risk if they become invasive. In both cases, the risk of malignancy must be weighed against the risk that surgery poses to the patient, which can be significant in some cases.
There is no global consensus on non-surgical management strategies for pancreatic cysts. Where surgery is not recommended, most guidelines favor surveillance with an increased regularity depending on how fast the cyst is growing and the likelihood of malignancy. MRI is the most commonly recommended method of surveillance. Here are examples from two different organizations on monitoring and managing low-risk cysts:
For cysts less than 3 cm, an MRI or CT scan is recommended after one year and then every subsequent two years for a total of five years.
For cysts less than 15 mm, yearly scans are recommended until the cyst is stable for three years. After this, the scan frequency can be extended to two years. Cysts greater than 15 mm should be examined every six months for the first year and then every subsequent year.
The regularity of follow-up imaging depends on the likelihood of recurrence and the treatment method. This means it will differ for every patient and every cyst type.
The AGA recommends MRI scans of the remaining pancreas every two years after surgery for individuals who have an invasive cyst with abnormal growth (dysplasia).
Two studies report a recurrence rate of 8 and 36 percent for invasive IPMNs, and one study found an 8.8 percent recurrence rate for non-invasive IPMNs.
Understanding the latest pancreatic cyst guidelines is crucial for effective diagnosis and management. Accurate diagnosis of cyst type using a combination of imaging, endoscopic procedures, and molecular techniques helps prevent unnecessary surgeries and ensures timely intervention for higher-risk cysts. Staying informed about these guidelines empowers patients and healthcare providers to make well-informed decisions regarding pancreatic cysts. Early detection and intervention are essential for preventing pancreatic cysts from progressing into adenocarcinoma, which carries a high mortality rate.
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