Guideline urges caution when assessing symptoms of pancreatic cysts

The American College of Gastroenterology guideline addresses common clinical questions about management and provides guidance regarding when to refer for additional evaluation.

A recent guideline from the American College of Gastroenterology on the diagnosis and management of pancreatic cysts suggests that clinicians use caution when determining the cause of symptoms, among other recommendations.

The guideline, which is based on a systematic review of the literature and on expert opinion, addresses common clinical questions about management of different types of pancreatic cysts and provides guidance regarding when to refer for additional evaluation. The authors noted that these recommendations do not apply to patients who have a strong family history of pancreatic cancer or those who have genetic mutations that predispose them to the disease. The guideline was published online by the American Journal of Gastroenterology on Feb. 27.

The guideline recommends that physicians take care when attributing symptoms to a pancreatic cyst, because most pancreatic cysts are asymptomatic and because nonspecific symptoms, when present, require clinical discernment. MRI and magnetic resonance cholangiopancreatography (MRCP) are the recommended tests of choice because they are noninvasive, lack radiation, and more accurately assess communication between the main pancreatic duct and the cyst, the guideline said. It also noted that pancreatic protocol CT and endoscopic ultrasound are excellent alternatives for patients who can't undergo MRI. The guideline recommended caution when using imaging to diagnose cyst type or concomitant malignancy because of concerns about accuracy. The accuracy of MRI or MRCP is 40% to 50% in diagnosing cyst type and 55% to 76% in determining whether it is benign versus malignant. The accuracy for CT and endoscopic ultrasound without fine-needle aspiration is similar.

Asymptomatic cysts that are diagnosed as pseudocysts on initial imaging or clinical history or that have a very low risk for malignant transformation do not require treatment or further evaluation, the guideline said. Endoscopic ultrasound with fine-needle aspiration and cyst fluid analysis should be considered for cysts with unclear diagnosis when results are likely to change management. Cyst fluid cytology should be used to assess the presence of high-grade dysplasia or pancreatic cancer if imaging results are not enough to warrant surgery, according to the guideline. Molecular markers may also help identify intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs), especially in these cases.

Patients who are fit for surgery should be offered cyst surveillance if they have asymptomatic cysts presumed to be IPMNs or MCNs, the guideline said. Patients with these types of cysts who have new-onset or worsening diabetes or whose cysts rapidly increase in size during surveillance may be at increased risk for malignancy and should receive short-interval MRI or endoscopic ultrasound plus fine-needle aspiration. The guideline noted that patients who have a solid pseudopapillary neoplasm should be referred to a multidisciplinary group for possible surgical resection. Surveillance should be discontinued in patients who are no longer candidates for surgery, the guideline said. It also noted that it is reasonable to assess the utility of continuing surveillance in patients who are older than age 75 years and that an individualized approach with informed discussions about surgery should be considered in patients ages 76 to 85 years.

The guideline also summarized the types and characteristics of pancreatic cysts and included additional recommendations on diagnosis, management, and surveillance. Most of the recommendations in the guideline are conditional and based on low- or very low-quality evidence, the authors noted. They stressed the need for prospective, multicenter studies to provide evidence that can inform future guidelines.