MKSAP quiz: Managing a serous cystadenoma
A 65-year-old woman is evaluated at a follow-up visit. She presented to the emergency department 2 weeks ago with a 2-day history of left-lower-quadrant abdominal pain. The radiology report shows a pancreatic cyst with all the imaging features of a serous cystadenoma. What is the most appropriate management?
A 65-year-old woman is evaluated at a follow-up visit. She presented to the emergency department 2 weeks ago with a 2-day history of left-lower-quadrant abdominal pain. CT revealed diverticulitis and a 15-mm cystic structure in the body of the pancreas. Her acute diverticulitis has resolved, and she now feels well. Colonoscopy is scheduled in 6 weeks. She has no other medical conditions and takes no medications. The radiology report indicates that the pancreatic cyst has all the imaging features of a serous cystadenoma.
Vital signs and other physical examination findings are normal.
Which of the following is the most appropriate management?
A. Endoscopic ultrasonography and fine-needle aspiration
B. MRI
C. Surgical resection
D. No further evaluation or intervention
MKSAP Answer and Critique
The correct answer is D. No further evaluation or intervention. This content is available to MKSAP 19 subscribers as Question 69 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate management for the patient's serous cystadenoma is no further evaluation or intervention (Option D). Characteristic findings of serous cystadenomas include multicystic, lobulated structures (sometimes described as a "bunch of grapes"), which may have a central fibrosis scar or calcification. Pancreatic cysts are being detected more frequently because of increased use of imaging and improved imaging techniques; these cysts may be found in 15% of individuals undergoing abdominal imaging. Cystic neoplasms of the pancreas are subcategorized as mucin-producing and non–mucin-producing cysts. Mucin-producing cysts, including intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, are thought to have malignant potential, but many never become malignant. Non–mucin-producing cysts, such as a serous cystadenoma, have no malignant potential and can often be identified by their characteristic imaging features. These cysts require no further evaluation unless symptomatic.
For patients in whom the diagnosis is unclear, endoscopic ultrasonography and fine-needle aspiration (Option A) can be performed for cytology, measurement of carcinoembryonic antigen level, and DNA analysis.
In the absence of high-risk features (e.g., main pancreatic duct dilation, cysts 3 cm or larger, change in the main duct diameter with distal parenchymal atrophy, and association with a solid mass), patients with mucinous cysts may undergo MRI surveillance (Option B), the frequency depending on many factors, including cyst size.
Surgical resection (Option C) of high-risk cysts is the only treatment option. In addition to the high-risk features just described, cysts in patients presenting with obstructive jaundice are also high risk. Surgical resection is recommended for nearly all mucinous neoplasms and main-duct intraductal papillary mucinous neoplasms if the patient is an appropriate surgical candidate. Mucinous cystic neoplasms occur almost exclusively in women in their fifth to seventh decades of life and are almost always located in the body or tail of the pancreas. These neoplasms have moderate malignant potential. Intraductal papillary mucinous neoplasms (IPMNs) are equally prevalent in men and women, usually appearing in their fifth to seventh decades of life. Branch-duct IPMNs are characterized by cystic structures that may appear throughout the pancreas. Imaging characteristics of main duct IPMNs include main pancreatic duct dilation and parenchymal atrophy. These neoplasms have variable malignant potential.
Key Points
- Mucin-producing cysts, including intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, are thought to have malignant potential.
- Non–mucin-producing cysts, such as a serous cystadenoma, have no malignant potential.