Long-term follow-up of neoplastic pancreatic cysts without high-risk stigmata: how often do we change treatment strategy because of malignant transformation?

Figures & data

Table 1. Current guidelines for surgery of intraductal papillary mucinous neoplasm (IPMN).

Guideline	Absolute indications for surgery	Relative indications for surgery
International Association of Pancreatology; Tanaka et al. 2012 [4]	Jaundice Enhancing nodule PD ≥10 mm	Cyst size ≥3 cm Thickened/enhancing cyst walls PD 5–9 mm Non-enhancing nodule Abrupt change caliber PD with distal pancreatic atrophy Recurrent pancreatitis
European guideline; Del Chiaro et al. 2013 [3]	Jaundice, diabetes, acute pancreatitis Nodule PD ≥5 mm Size ≥4 cm	Rapidly increasing size Elevated serum CA 19-9
American Gastroenterological Association; Vege et al. 2015 [5]	Solid component and PD ≥5 mm (on MRI and EUS) Cytology positive for malignancy

Indication for surgery of intraductal papillary mucinous neoplasm (IPMN) according to the International Association of Pancreatology, European guidelines of the European Study Group on Cystic Tumours of the Pancreas and American Gastroenterological Association institute guideline.[3,4] PD: pancreatic duct.

Figure 1. Patient selection. MT/MD-IPMN: mixed type/main duct intraductal papillary mucinous neoplasm; MCN: mucinous cystic neoplasm; SB-IPMN: side branch-intraductal papillary mucinous neoplasm; solid pseudopap. Neoplasm: solid pseudopapillary neoplasm.

Table 2. Patient characteristics.

	N = 146
Age, mean (SD) years	61 (11.0)
Female, n (%)	84 (58)
Abdominal complaints, n (%)	78 (53)
Jaundice, n (%)	1 (1)
Pancreatitis, n (%)	19 (13)
Number of cysts per patient (%)
1	87 (60)
2	12 (8)
3	13 (9)
>3	34 (23)
Location of cysts (%)
Head	54 (37)
Body	31 (21)
Tail	17 (12)
Multifocal	43 (30)
Peripancreatic	1 (1)
Size cyst
<1 cm, n (%)	10 (7)
≥1 cm, n (%)	136 (93)
Median (range) in cm	2.4 (1.0–12.6)
Size PD
<5 mm, n (%)	136 (93)
5–9 mm, n (%)	10 (7)
≥10 mm, n (%)	0
Nodule, n (%)	0

PD: pancreatic duct.

Table 3. Characteristics of patients who developed an indication for surgery.

Age, sex	FU, mo	N cysts, location	Size start (cm)	Size last (cm)	Indication for surgery	Timing	Presumed diagnosis	Definitive diagnosis	Dysplasia
A
46, F	15	1, corpus	1.1	1.2	Thickened cyst wall	Routine FU	NET	NET	Low-grade
61, F	25	3, multifocal	3.0	4.0	Changed diagnosis	Routine FU	MCN	SB-IPMN	Low-grade
29, F	34	1, peripancreatic	2.5	3.5	Changed diagnosis	Routine FU	MCN	Lymphang.	None
48, F	67	1, corpus	2.6	3.3	Changed diagnosis	Routine FU	MCN	MCN	None
58, M	10	1, head	3.0	4.8	Suspected nodule 10 mm, rapid increased size	Routine FU	SB-IPMN	PFC	None
61, F	50	3, multifocal	1.9	2.5	Solid lesion distant from cyst	Interval change	SB-IPMN	SB-IPMN^a	PDAC not from cyst
78, M	16	3, multifocal	2.4	5.4	Rapid increase in size	Routine FU	SB-IPMN
74, F	86	3, multifocal	2.0	4.5	Suspected nodule 26 mm	New referral^b	SB-IPMN
46, F	7	>3, head	2.8	2.5	PD 12 mm	Routine FU	MT-IPMN	MT-IPMN	Borderline
73, M	13	1, head	5.5	5.8	Suspected nodule 8 mm, PD 8 mm	Routine FU	MT-IPMN	MT-IPMN	Borderline
62, F	27	1, corpus	2.0	3.2	PD 10 mm, recurrent pancreatitis	Interval change	MT-IPMN	MT-IPMN	Borderline
B
53, F	33	1, head	5.5	6.9	Pain	Interval change	SCN	SCN	None
44, M	10	1, tail	1.8	1.9	Recurrent pancreatitis	Interval change	SB-IPMN	SB-IPMN	Low-grade

Patient developed an indication for surgery during follow-up (FU) because of (A) suspicion of malignant progression or (B) a symptomatic pancreatic cyst. SCN: serous cystic neoplasm; IPMN: intraductal papillary mucinous neoplasm; SB: side branch; MT: mixed type; MD: main duct; NET: neuroendocrine tumor; MCN: mucinous cystic neoplasm; PFC: pancreatic fluid collection.

^aNo histopathological diagnosis was made.

^bPatient was discharged from surveillance because of inoperable condition, but presented in another hospital that was unknown of the medical history, after which patient was referred to our center.

Tanaka M, Fernández-del Castillo C, Adsay V, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12:183–197.

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Del Chiaro M, Verbeke C, Salvia R, et al. European experts consensus statement on cystic tumours of the pancreas. Dig Liver Dis. 2013;45:703–711.

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Vege SS, Ziring B, Jain R, et al. American Gastroenterological Association Institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 2015;148:819–822.

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