Management A Guideline Based Approach to the Incidental Pancreatic Cysts. Common Cystic Pancreatic Neoplasms.

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1 Management 2016 A Guideline Based Approach to the Incidental Pancreatic Cysts ISMRM 2016 Masoom Haider, MD, FRCP(C) Professor of Radiology, University of Toronto Clinician Scientist, Ontario Institute of Cancer Research Senior Scientist, Sunnybrook Research Institute Chief, Dept of Medical Imaging Sunnybrook Health Sciences Center masoom.haider@sunnybrook.ca Variability in radiologist recommendations Guidelines Evolving based on poor evidence Symptomatic lesions much more likely to undergo surgery/intervention Radiology of particular importance in asymptomatic patients Lesions in the tail have lower threshold for surgery A trend towards less surgery and more surveillance Expanding role of Endoscopic Ultrasound Cost containment issues of unending followup 2 Approach Classify into types based on imaging features Follow Guidelines Individualize treatment Common Cystic Pancreatic Neoplasms Intraductal Papillary Mucinous Neoplasm Serous Cystadenoma Mucinous Cystic Neoplasm Unable to classify 3 4 Tanaka criteria (or Fukuoka consensus guidelines) Incidental Pancreatic Cyst 5 6 1

2 Endoscopic US (EUS) Operator dependent Morphologic analysis Cyst fluid analysis - CEA > 200ng/ml 80% accurate for mucinous cyst Low CEA does not exclude mucinous cyst Serous cysts typically have low amylase and CEA KRAS mutation and cytology investigational - Tissue analysis limited by sampling - Sens 60%, Spec 90% 7 8 Pathology Pancreatic Intraepithelial Neoplasia (PanIN) Spectrum of dysplasia from low grade to high grade May have invasive cancer female mid 40 s 1. No further follow-up 3. Follow-up in 12 months 4. Follow-up > 12 months 5. EUS (Endoscopic ultrasound) 6. Surgery 8 mm no enhancement no nodules Yu J et al. Clin Cancer Res 2012;18: Jaundice, enhancing solid component main duct >= 10mm female mid 40 s 1. No further follow-up 3. Follow-up in 12 months 4. Follow-up > 12 months 5. EUS (Endoscopic ultrasound) 6. Surgery No 8 mm no enhancement no nodules >= 3cm, thickened enhancing walls main duct 5-9mm non enhancing nodule, change in duct caliber with distal atrophy No Size <1cm CT or MRI in 2-3 years

3 Mixed Main and Side Branch IPMN 73yo male IPMN Predictors of Invasion/Malignancy Main duct dilation* Solid components** Size >= 3cm Growth >5mm (not a good predictor) Multifocality not a good predictor *Levy P. Clin Gastroenterol Hepatol 2006; 4: **Manfredi R. Radiology 2009; 253: non-invasive with papillary components Jaundice, enhancing solid component main duct >= 10mm female mid 40 s Consider surgery if clinically appropriate No further follow-up 3. Follow-up in 12 months 4. Follow-up > 12 months 5. EUS (Endoscopic ultrasound) 6. Surgery 16 Jaundice, enhancing solid component main duct >= 10mm No T2 3cm MPD 4mm 70yo male Consider surgery if clinically appropriate Pre-contrast T1 Fat Sat >= 3cm, thickened enhancing walls main duct 5-9mm non enhancing nodule, change in duct caliber with distal atrophy EUS Mural Nodule Main duct features of involvement Positive cytology Inconclusive moderate dysplasia Post-contrast T1 Fat Sat Close surveillance MRI/EUS q3-6mo Consider surgery in young fit patients 18 3

4 Multifocal IPMN Side Branch Low grade dysplasia 36yo female 1. Follow-up in 3 months 3. Follow-up in12 months 4. EUS 5. Surgery 71yo male Positive resection margin 19 Multifocal up to 30% Whole pancreas 5-10% cm, elderly female 1. Follow-up in 6 months 2. Follow-up in 12 months 3. Follow-up in 24 months 4. EUS 5. Surgery 21 All evidence was graded as low quality All recommendations conditional except surgery in specialized centers 1. <3cm, no duct dilation or solid components 1yr x 1 then 2yr x 2 2. If 2 of 3 (>=3cm, dilated main duct, solid component) then EUS/ FNA (sens 60/spec 90) 3. If EUS/FNA neg the MRI q1yr, then q2yr 4. If change in characteristic such as size >=3cm, increasing duct dilation or new solid component the EUS/FNA 5. If no change in 5 years or if patient not a surgical candidate discontinue surveillance 6. If both solid component and dilated pancreatic duct and/or concerning features on EUS and FNA then surgery 22 Serous Cystadenoma -Growth Use of Gd for Followup may not be necessary* *Macari M. AJR Am J Roentgenol 2009; 192:

5 Incidental Unilocular Pancreatic Cyst Incidental Unilocular Pancreatic Cyst Surveillance Recommendation: 1. Annual surveillance 2. Single one year follow-up then stop if stable 3. q1yr, then q2 yr x 2 then stop if stable 4. No follow-up required If <65 increased risk of developing malignancy (~3-4x) not too different from smoking risk of PDAC 1. Decrease interval if younger and omit if limited life expectancy 2. Limited T2 MRI for followup 3. Cysts <1.5cm need not be immediately characterized Future All evidence was graded as low quality All recommendations conditional except surgery in specialized centers 1. <3cm, no duct dilation or solid components 1yr x 1, 2yr x 2 2. If 2 of 3 (>=3cm, dilated main duct, solid component) then EUS/ FNA (sens 60/spec 90) 3. If EUS/FNA neg the MRI q1yr, then q2yr 4. If change in characteristic such as size >=3cm, increasing duct dilation or new solid component the EUS/FNA 5. If no change in 5 years or if patient not a surgical candidate discontinue surveillance 6. If both solid component and dilated pancreatic duct and/or concerning features on EUS and FNA then surgery Risk stratification methods based on imaging, life expectancy, history, and non-imaging biomarkers (cyst aspiration) >5% risk or 5x general population PancPro score Hopkins DWI/MRS other MRI approaches Watch for evolution of guidelines as long term outcomes manifest

6 Summary 31 Pancreatology 12 (2012)

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