Management of serous cystic neoplasms of the pancreas

Abstract

Pancreatic serous cystadenomas are uncommon benign tumours that are often found incidentally on routine imaging examinations. Radiological imaging techniques alone have proven to be suboptimal to fully characterize cystic pancreatic lesions. Endoscopic ultrasound, with the addition of fine-needle aspiration in difficult cases, has showed greater diagnostic accuracy than conventional imaging techniques. The best management strategy of these neoplasms is still debated. Surgery should be limited only to symptomatic and highly selected cases and most of the patients should only be strictly monitored. In the current paper, we provide an updated overview on pancreatic serous cystadenomas, focusing our attention on epidemiology, clinical characteristics and diagnostic evaluation; finally, we also discuss different management strategies and areas for future research.

Keywords:

• confocal laser endomicroscopy
• endoscopic ultrasound
• fine-needle aspiration
• metabolomic analysis
• mucinous cystic neoplasms
• pancreatic cysts
• serous cystadenocarcinoma
• serous cystadenoma
• surgery

Acknowledgements

The authors thank Adele Fornelli for the pathological images and Marta Fiscaletti for the radiological images.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Pancreatic cystic lesions are being increasingly detected with the more widespread use of diagnostic techniques and improvements in imaging technology.

• Unlike mucinous cystic neoplasms, serous cystadenomas (SCAs) of the pancreas are considered benign tumors. Therefore, a correct diagnosis is mandatory to avoid unnecessary pancreatic surgery and ensure patients excluding a malignant disease.

• Radiological imaging techniques alone have proven to be suboptimal to fully characterize cystic pancreatic lesions.

• Endoscopic ultrasound, allowing for cytological and biochemical analyses of the cystic fluid obtained by fine-needle aspiration, has showed greater diagnostic accuracy than conventional imaging techniques.

• Carcinoembryonic antigen dosage on cystic fluid is the most accurate test available to differentiate pancreatic cystic lesions.

• The role of genetic testing, metabolomic analysis and needle-based confocal laser endomicroscopy during endoscopic ultrasound-fine-needle aspiration procedure is under investigation and definitively represents an area of future research in the diagnosis of pancreatic cystic lesions.

• Serous neoplasms of the pancreas present an extremely small risk of malignancy; therefore, the vast majority of them should not undergo surgical resection.

• Surgery should be limited only to symptomatic and highly selected cases of SCAs and the majority of patients should be strictly monitored to observe whether any modification in size or onset of symptoms does occur.

• The best follow-up strategy of SCAs is still debated; however, imaging on an annual or even bi-annual basis is advisable.