Mini-Symposium
Management and outcomes of pancreatic cystic lesions

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Abstract

The management of pancreatic cystic lesions offers a challenge to clinicians. Mucinous cystic lesions pose a low risk of the development of neoplasia that must be taken into account in long-term management. Although the natural history has not been well defined, it is likely that malignant change in the mucinous epithelium takes place over years, very similar to what is observed with Barrett's esophagus. The traditional therapy of mucinous cystic lesions has been surgical resection. Lesions in the head of the pancreas will require a Whipple resection whereas tail lesions are managed with a distal pancreatectomy and splenectomy. In patients at high risk for surgical resection, the risk/benefit ratio may be excessively high, not supporting the use of resection therapy. Ethanol ablation therapy has been thoroughly studied in hepatic, renal, and thyroid cysts. Epithelial ablation with ethanol appears to be highly effective and relatively safe. Recently, ethanol ablation has been evaluated in pancreatic cystic neoplasms. In macrocystic lesions between 1 and 5 cm, ethanol lavage will result in epithelial ablation and cyst resolution in a high percentage of patients. Pancreatitis is rarely observed clinically and is not present in resection specimens. A randomised prospective clinical trial is currently underway.

Introduction

Pancreatic neoplasms are relatively unique in that a significant percentage of the lesions are primarily cystic [1]. In the past cystic neoplasms of the pancreas were thought to be relatively rare, but with an improved understanding of the appearance of the lesion on cross-sectional imaging, there has been a dramatic increase in the diagnosis [2]. Although most pancreatic cystic lesions are discovered incidentally and produce few symptoms, invasive lesions may come to medical attention because of jaundice, pancreatitis, or abdominal pain [3].

In terms of malignant potential and management, pancreatic cystic lesions are usually divided into mucinous and non-mucinous lesions. There are three types of mucinous lesions: benign mucinous cystadenomas, malignant mucinous cystic lesions, and intra-ductal papillary mucinous neoplasms (IPMNs). The non-mucinous lesions include serous cystadenomas, cystic endocrine tumours and other rare lesions. There is a significant difference in the natural history and survival in mucinous and non-mucinous lesions since the risk of malignancy in cystic endocrine tumours is low and the risk in serous lesions is even lower [4].

Section snippets

Prevalence

The prevalence of pancreatic cystic lesions is surprisingly common. In autopsies, 73 of 300 cases (24.3%) had evidence of a neoplastic cystic lesion [5]. The prevalence of cysts increases with age. Additional studies have demonstrated that early pancreatic cancer arises from cystic neoplasia [6].

The prevalence of pancreatic cysts in the United States has been estimated in patients undergoing MRI for non-pancreatic diseases [7]. Nearly 20% of 1444 patients had at least one pancreatic cyst. About

Pathology

Serous cystadenomas are benign, solitary, cystic tumours that arise from the centro-acinar epithelium. The most common serous lesion is microcystic, composed of a dense collection of sub-centimeter cysts. Macrocystic serous cystadenomas are composed of far fewer cysts, and the diameter of each cyst varies from microcystic to large cavities. The presence of discrete, large cystic cavities simulates the appearance of a mucinous lesion. Since the cyst fluid from serous lesions contains no mucin,

Treatment

Traditionally, mucinous lesions have been managed by surgical resection [19]. The decision to resect a lesion, however, is based on the presence or absence of symptoms, the risk of malignancy, and the surgical risk of the patient (Table 2). High-risk patients with low-grade cystic neoplasms may be monitored with periodic CT/MRI scanning or EUS-FNA. Small cystic lesions in the elderly can be safely monitored.

The increasing safety of surgical resection has encouraged the use of surgical resection

Conflict of interest statement

The undersigned, aware about all civil and criminal liabilities involved declares, under Article 48 Paragraph 25 D.L. 269/03, not having (not being subject to) any conflict of interest in giving commercial support in connection to the abovementioned event.

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