Diagnosis and Management of Pancreatic Cystic Neoplasms

Pancreatic cystic neoplasms (PCNs) are being diagnosed with increasing frequency. PCNs have diverse presentations, natural history, and biological behavior. Obtaining an accurate diagnosis of the type of cyst and assessing the potential for malignancy are crucial in determining the appropriate management strategy. Cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI), at experienced centers, is effective in defining the type of cyst as well as identifying high-risk features. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) and cyst fluid analysis can categorize and risk-stratify cysts and is the test of choice in selected patients. However, there is currently no "perfect" test and studies have demonstrated substantial misdiagnosis and over-treatment of benign cysts using standard clinical, imaging, and cyst fluid analyses. Patients with symptomatic cysts or cysts with high-risk features suggestive of malignancy should be considered for surgical resection. Patients with low-risk PCNs can be placed in surveillance protocols with interval imaging. Various gastrointestinal societies have put forth evidence- or consensus-based guidelines that provide a framework for management of PCNs. However, the management can be complex and should ideally be planned in a multidisciplinary fashion by experienced specialists. Recent investigations using molecular markers to risk-stratify cysts offer promise in the future for an effective and accurate management strategy.