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Management of pancreatic pseudocysts in pediatric oncology patients
Yousef El-Gohary1, Sara Mansfield1, Jessica Staszak2
1Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA.
Insights
Pediatric oncology patients with pancreatic pseudocysts, often linked to PEG-asparaginase, can frequently be managed conservatively. Intervention for these pseudocysts is best guided by patient symptoms, not solely by size.
Area of Science:
- Pediatric Gastroenterology
- Oncology
- Medical Interventions
Background:
- Pancreatic pseudocysts in children are often managed based on adult protocols, where larger cysts typically require intervention.
- This study focuses on pediatric oncology patients, a population with unique considerations for pancreatic pseudocyst management.
- The role of medications, particularly PEG-asparaginase, in the development of pancreatic pseudocysts in this cohort is explored.
Purpose of the Study:
- To review the clinical course and outcomes of pancreatic pseudocysts in pediatric oncology patients.
- To evaluate the effectiveness of conservative versus interventional management strategies for pediatric pancreatic pseudocysts.
- To determine the optimal criteria for intervention in medication-induced pancreatic pseudocysts in children undergoing cancer treatment.
Main Methods:
- A 15-year retrospective review of pediatric oncology patients diagnosed with pancreatitis and pancreatic pseudocysts.
- Analysis of patient demographics, cancer type, medications, pseudocyst characteristics (size, imaging), treatment, and outcomes.
- Comparison of conservative management versus procedural interventions (percutaneous drainage, surgical cyst-enteric drainage, ERCP with stenting).
Main Results:
- Of 132 patients with pancreatitis, 31 developed pancreatic pseudocysts, with 84% associated with PEG-asparaginase.
- The median pseudocyst size was 7.6 cm, with 59% exceeding 6 cm, yet 71% were successfully managed conservatively.
- Intervention was indicated by worsening pain in 29% of cases, with conservative management or percutaneous drainage being most common.
Conclusions:
- Most medication-induced pancreatic pseudocysts in pediatric cancer patients can be managed non-operatively.
- Transgastric percutaneous drainage is a viable option for select cases requiring intervention.
- Patient symptoms, particularly pain, are reliable indicators for intervention, irrespective of pseudocyst size.
Background:
Management of children with pancreatic pseudocysts has historically been adopted from the adult experience where pancreatic pseudocysts greater than 6 cm are unlikely to resolve without intervention. We reviewed the clinical course of pediatric oncology patients with pancreatic pseudocysts.
Methods:
A retrospective review of patients treated over a 15-year period was performed. Variables evaluated included cancer type, medications administered, clinical and imaging characteristics of the pancreatic pseudocysts, treatment and outcome.
Results:
A total of 132 patients with a median age of 13 (IQR, 9-17) years were identified with pancreatitis. Thirty-one (23.5%) patients developed a pancreatic pseudocyst, of which 84% were associated with PEG-asparaginase treatment. The median pseudocyst size was 7.6 (IQR, 4.4-9.9) cm with 59% being greater than 6 cm. Twenty-two (71%) patients with a pancreatic pseudocyst underwent successful conservative management, while only 9 (29%) required procedural intervention including six percutaneous drainage, one of whom recurred and required surgical cyst-enteric drainage. Two other patients had primary surgical cyst-enteric drainage and one patient underwent endoscopic retrograde cholangiopancreatography with stenting. The indication for intervention was worsening pain rather than pseudocyst imaging characteristics, size or serum amylase/lipase.
Conclusion:
Most medication-induced pancreatic pseudocysts in children being treated for cancer, regardless of pseudocyst size, can be managed non-operatively or with transgastric percutaneous drainage. The need for intervention can be safely dictated by patient symptoms.
Level Of Evidence:
III.
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