European experts consensus statement on cystic tumours of the pancreas

Abstract

Cystic lesions of the pancreas are increasingly recognized. While some lesions show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). European expert pancreatologists provide updated recommendations: diagnostic computerized tomography and/or magnetic resonance imaging are indicated in all patients with cystic lesion of the pancreas. Endoscopic ultrasound with cyst fluid analysis may be used but there is no evidence to suggest this as a routine diagnostic method. The role of pancreatoscopy remains to be established. Resection should be considered in all symptomatic lesions, in mucinous cystic neoplasm, main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm as well as in branch duct intraductal papillary mucinous neoplasm with mural nodules, dilated main pancreatic duct >6 mm and possibly if rapidly increasing in size. An oncological partial resection should be performed in main duct intraductal papillary mucinous neoplasm and in lesions with a suspicion of malignancy, otherwise organ preserving procedures may be considered. Frozen section of the transection margin in intraductal papillary mucinous neoplasm is suggested. Follow up after resection is recommended for intraductal papillary mucinous neoplasm, solid pseudo-papillary neoplasm and invasive cancer.

Introduction

Cystic lesions of the pancreas are increasingly recognized because of the improvement of imaging techniques during the last decades. Recently, the prevalence of cystic lesions in the pancreas has been estimated up 3% using computerized tomography (CT) and up to 20% using magnetic resonance (MR) imaging technology [1], [2], [3]. The latter is coherent with post-mortem examined pancreata demonstrating cystic lesions smaller than 1 cm up to a quarter of cases [4]. Moreover, a prevalence of 45% was recently reported in a cohort study using magnetic resonance cholangiopancreatography (MRCP) for non-pancreatic indications [5]. Thus, cystic lesions of the pancreas constitute a significant clinical entity.

Pancreatic cysts form a heterogeneous group of tumours. While some show benign behaviour, others have an unequivocal malignant potential and, in addition, are precursors of pancreatic ductal adenocarcinoma [6] such that their detection allows prevention or early treatment of this disease. It is therefore of utmost importance and one of the most urgent challenges for pancreatologists today to improve the diagnosis, treatment and follow-up of cystic lesions of the pancreas, and to define criteria for the distinction of benign from malignant, or potentially malignant, lesions. Currently, guidelines dedicated only mucinous cystic neoplasms exist, while comprehensive guidance for the diagnosis and management of all cystic tumours of the pancreas are lacking [7], [8]. Since there is a lack of prospective randomized trials in this field, no strong evidence are available today.

The aim of this European consensus statement is to provide guidelines for cystic tumours of the pancreas regarding their definition, classification, and diagnosis, the clinical patient management and assessment of biopsy or surgical specimens. This will not only provide up-to-date guidance for the management of pancreatic cystic neoplasms, but also allow harmonisation of diagnosis and treatment between centres, and therewith ensure comparability of data.