Multidisciplinary diagnostic and therapeutic approaches to pancreatic cystic lesions

Pancreatic cystic lesions are commonly encountered today with the routine use of cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). The majority of patients discovered to have a pancreatic cyst are completely asymptomatic; yet the presence of such a finding instills fear in the minds of both patient and physician, as the concern for malignant transformation to pancreatic cancer is great despite the relatively low overall likelihood of cyst progression. Not all cysts in the pancreas represent pancreatic cystic neoplasms (PCNs), and not all PCNs have significant malignant potential. Mucinous PCNs are the most concerning, as these lesions have the greatest potential for cancerous transformation to adenocarcinoma. Within the group of mucinous PCNs, intraductal papillary mucinous neoplasms (IPMNs) involving the main pancreatic duct are the most worrisome, and surgical resection should be pursued if the patient has appropriate operative risks. IPMN lesions involving the branch ducts, and mucinous cystadenomas, have a lower likelihood for malignancy, and they may be closely followed for the development of any worrisome or high-risk features. Surveillance of known PCNs is performed with a combination of CT, MRI and endoscopic ultrasound (EUS). EUS-guided fine-needle aspiration (EUS-FNA) may be used to assess cyst fluid cytology, and also to detect cyst fluid amylase level, carcinoembryonic antigen level, and DNA molecular analysis in certain cases. The presence or absence of specific cyst morphological features, as well as the cyst fluid analysis, is what enables the physician to guide the patient towards continued surveillance, versus the pursuit of surgical resection.