New ACG guidelines address changing landscape of pancreatic cyst management
The American College of Gastroenterology has released new guidelines on the diagnosis and management of pancreatic cysts.
The society developed the recommendations to help practicing gastroenterologists choose the best plan for patients with a condition that has become much more common in recent years, according to Grace Elta, MD, FACG, of the Division of Gastroenterology at the University of Michigan.
“Pancreatic cysts are being diagnosed so much more commonly in the last 10 years than they have in the previous 30 years; it’s amazing the rate were diagnosing these at,” Elta told Healio Gastroenterology and Liver Disease. “This is really a common clinical GI problem for the practitioner. The ACG guidelines have always been aimed at the practicing GI doc out in the field. What do they need to help them get through their day?”
Elta credits advances in CAT scans and MRIs for the increase in discovery of pancreatic cysts. In addition to better quality, Elta said patients are undergoing the tests much more often than before.
“CAT scan and MRI have improved dramatically in the last 15 years or so. So, they’re now able to diagnose pancreatic cysts that in the past they couldn’t see,” Elta said. “They’re performed much more frequently for other indications. Most of these cysts are incidental findings. When someone comes up with an incidental finding, then they’re sent to a GI to evaluate.”
Although incidence of pancreatic cysts has gone up, the rates of pancreatic cancer — which can develop from some kinds of cysts — have stayed the same. Elta and colleagues sought to find a balance between the need for early detection of pre-cancerous cysts and avoiding invasive and costly surgeries and surveillance.
“I think the take home message is to learn to identify the kind of cyst it is, because some cysts don’t need surveillance at all,” Elta said. “If you decide it is a cyst that has potential to become cancerous, then follow the guidelines in terms of how often you’re going to surveil and who.”
The guidelines cover pancreatic cyst diagnosis, management and surveillance. Highlights of the recommendations includes:
- Use caution when attributing symptoms to a pancreatic cyst. Most pancreatic cysts are asymptomatic and the nonspecfic nature of symptoms requires clinical discernment.
- Patients who are not medically fit for surgery should not undergo further evaluation of incidentally found pancreatic cysts, irrespective of cyst size.
- Patients with asymptomatic cysts that are diagnosed as pseudocysts on initial imaging and clinical history, or that have a very low risk of malignant transformation (such as serous cystadenomas) do not require treatment or further evaluation.
- Cyst surveillance should be offered to surgically fit candidates with asymptomatic cysts that have some, albeit low, risk for pancreatic cancer.
- Cancer risk does not diminish over time, so surveillance must continue unless the patient is no longer a surgical candidate
“We try to address all the common questions the practitioner needs to deal with,” Elta said. “The field has changed a fair amount, which is why our guideline is different from previous ones. Data keep coming in.” – by Alex Young
Disclosures: The authors reported no relevant financial disclosures.