In the Journals

AGA guideline recommends change in diagnosis, management of asymptomatic pancreatic cysts

The American Gastroenterological Association has released a new guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts, which recommends some significant changes regarding surveillance periods and surgery.

“Pancreatic cysts are a common occurrence that increases with age, but based on the best available evidence, the risk of developing into cancer is low,” Paul Moayyedi, MD, PhD, AGAF, a guideline co-author from McMaster University in Ontario, Canada, said in a press release. “This AGA guideline represents a significant change in current clinical practice for managing pancreatic cysts because they advocate less frequent follow-up and a higher threshold before offering endoscopic ultrasound and/or surgery. Consistent use of the recommendations should decrease inadvertent harm to patients and reduce the costs of health care delivery.”

The guideline recommendations include:

  • Patients should understand risks and benefits before starting a surveillance program;
  • Patients with cysts smaller than 3 cm without a solid component or a dilated pancreatic duct should receive surveillance MRI in 1 year and then every 2 years for a total of 5 years if no change in size or characteristics occurs;
  • Cysts should be examined with endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) if they have two or more high-risk features (eg, ≥ 3 cm, dilated main pancreatic duct or associated solid component);
  • After non-concerning EUS-FNA results, patients should receive surveillance MRI after 1 year and then every 2 years;
  • EUS-FNA is indicated in the event of significant changes in cyst characteristics (eg, solid component, increased size of pancreatic duct, and/or diameter ≥ 3 cm);
  • If no significant changes in cyst characteristics occur after 5 years of surveillance, or if patient is no longer a candidate for surgery, continued surveillance is not suggested;
  • Surgery is recommended for patients with both a solid component and a dilated pancreatic duct and/or concerning EUS-FNA results;
  • Patients should be referred to an expert center for surgery;
  • MRI surveillance every 2 years is recommended for patients with invasive cancer or dysplasia in a surgically resected cyst; and
  • Routine surveillance of cysts without high-grade dysplasia or malignancy at surgical resection is not suggested.

David S. Weinberg, MD

David S. Weinberg

“Other guidelines may offer different recommendations, but the evidence would not support the certainty of their alternative positions,” David S. Weinberg, MD, MSc, AGAF, chair of the AGA Guidelines Committee, and colleagues wrote in an accompanying editorial. “There is simply not enough evidence in the current literature to have even a modest degree of certainty of the benefits of surveillance. This lack of evidence has been seen by some as reason to be as aggressive as possible so that no malignancy is missed. However, this approach will also expose many patients to risk and, on occasion, unnecessary interventions.” – by Adam Leitenberger

Disclosure: The authors report no relevant financial disclosures.

The American Gastroenterological Association has released a new guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts, which recommends some significant changes regarding surveillance periods and surgery.

“Pancreatic cysts are a common occurrence that increases with age, but based on the best available evidence, the risk of developing into cancer is low,” Paul Moayyedi, MD, PhD, AGAF, a guideline co-author from McMaster University in Ontario, Canada, said in a press release. “This AGA guideline represents a significant change in current clinical practice for managing pancreatic cysts because they advocate less frequent follow-up and a higher threshold before offering endoscopic ultrasound and/or surgery. Consistent use of the recommendations should decrease inadvertent harm to patients and reduce the costs of health care delivery.”

The guideline recommendations include:

  • Patients should understand risks and benefits before starting a surveillance program;
  • Patients with cysts smaller than 3 cm without a solid component or a dilated pancreatic duct should receive surveillance MRI in 1 year and then every 2 years for a total of 5 years if no change in size or characteristics occurs;
  • Cysts should be examined with endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) if they have two or more high-risk features (eg, ≥ 3 cm, dilated main pancreatic duct or associated solid component);
  • After non-concerning EUS-FNA results, patients should receive surveillance MRI after 1 year and then every 2 years;
  • EUS-FNA is indicated in the event of significant changes in cyst characteristics (eg, solid component, increased size of pancreatic duct, and/or diameter ≥ 3 cm);
  • If no significant changes in cyst characteristics occur after 5 years of surveillance, or if patient is no longer a candidate for surgery, continued surveillance is not suggested;
  • Surgery is recommended for patients with both a solid component and a dilated pancreatic duct and/or concerning EUS-FNA results;
  • Patients should be referred to an expert center for surgery;
  • MRI surveillance every 2 years is recommended for patients with invasive cancer or dysplasia in a surgically resected cyst; and
  • Routine surveillance of cysts without high-grade dysplasia or malignancy at surgical resection is not suggested.

David S. Weinberg, MD

David S. Weinberg

“Other guidelines may offer different recommendations, but the evidence would not support the certainty of their alternative positions,” David S. Weinberg, MD, MSc, AGAF, chair of the AGA Guidelines Committee, and colleagues wrote in an accompanying editorial. “There is simply not enough evidence in the current literature to have even a modest degree of certainty of the benefits of surveillance. This lack of evidence has been seen by some as reason to be as aggressive as possible so that no malignancy is missed. However, this approach will also expose many patients to risk and, on occasion, unnecessary interventions.” – by Adam Leitenberger

Disclosure: The authors report no relevant financial disclosures.