Table 3.
An overview of four most recent guidelines on diagnosis and management of pancreatic cystic neoplasms [6, 8, 10, 95]
| Revised EU guideline (2018) | Revised Fukuoka guideline (2017) | ACG guideline (2018) | AGA guideline (2015) | |
|---|---|---|---|---|
| Diagnostic work-up | MRI: 1st choice CT: 2nd choice* EUS: supplementary FNA: in case of mural nodules, septations or indefinite imaging Serum 19-9 |
MRI: 1st choice CT: 2nd choice* EUS: for worrisome features FNA: in case of indefinite imaging; discouraged in case of high-risk/worrisome features Serum 19-9 |
MRI: 1st choice EUS/CT: alternative FNA: in case of indefinite imaging, high risk characteristics, cysts > 2 cm (differentiation mucinous and non-mucinous) Serum 19-9 |
MRI: 1st choice EUS: high-risk features FNA: in case of ≥ 2 high-risk features or significant change of high-risk feature |
| MD-/MT-IPMN: indications for surgery | Surgically fit patients | Surgically fit and ≥ 1 high-risk stigmata (see below) | Reference to multidisciplinary group in case of main-duct involvement | Not mentioned |
| BD-IPMN: high-risk features/indications surgery | Absolute indications: Solid mass Enhancing mural nodule ≥ 5 mm MPD ≥ 10 mm HGD/carcinoma in cytology Jaundice Relative indications: Cyst growth ≥ 5 mm/year Cyst size ≥ 4 cm Enhancing mural nodule < 5 mm MPD 5–9.9 mm Serum CA 19-9 ≥ 37 U/ml New-onset DM Acute pancreatitis |
High-risk stigmata: Enhancing mural nodule > 5 mm MPD > 10 mm Jaundice Worrisome features: Growth ≥ 5 mm/2 years Cyst size ≥ 3 cm Enhancing mural nodule < 5 mm Enhancing thickened cyst wall MPD 5–9 mm PD calibre change Elevated serum CA 19-9 Pancreatitis |
High-risk characteristics: Mural nodule/solid component MPD > 5 mm PD calibre change + atrophy Cyst size ≥ 3 mm Cyst growth > 3 mm/year HGD/carcinoma in cytology Jaundice Acute pancreatitis Elevated serum CA 19-9 New-onset DM |
High-risk features: Solid component Dilated MPD Cyst size ≥ 3 cm |
| Duration surveillance | As long as fit for surgery | As long as fit for surgery | As long as fit for surgery Individualized approach for age 76–85 years |
Discontinue after 5 years if no significant change has occurred |
| Surveillance intervals | 6 months (1st year), then yearly | < 1 cm: 6 months, then 2 yearly 1–2 cm: 6 months (1st year), yearly (2 years), then 2 yearly 2–3 cm: 3–6 months (1st year), then yearly > 3 cm: 3–6 months |
< 1 cm: 2 years 1–2 cm: 1 year 2–3 cm, clear IPMN/MCN: 6–23 months. Shorter interval for new-onset DM or cyst growth > 3 mm/year |
At years 1, 3 and 5 |
| Indication for surgery | ≥ 1 Absolute indication ≥ 1 Relative indication without significant co-morbidities ≥ 2 Relative indications for patients with significant co-morbidities |
≥ 1 High risk stigmata ≥ 1 Worrisome feature and ≥ 1 of the following: Definite mural nodule, MPD involvement Suspect cytology Consider: cyst > 2 cm in young and fit patient |
Decided by multidisciplinary team. Referral in case of jaundice or ≥ 1 of the following: MPD > 5 mm, Cyst size ≥ 3mm Calibre change MPD MPD involvement HGD/PDAC cytology Mural nodule |
Solid component and dilated MPD and/or concerning features on EUS-FNA |
| Surveillance after resection | Malignancy: according to PDAC guidelines HGD/MD-IPMN: 6 months (1st 2 years), then yearly LGD: as non-operated |
Malignancy: according to PDAC guideline 2x/year in case of one of the following: family history of PDAC, surgical margin with HGD, non-intestinal type IPMN Other patients Every 6–12 months |
Malignancy: according to PDAC guidelines HGD: every 6 months Low-/intermediate grade dysplasia: every 2 years |
Dysplasia/malignancy: every 2 years If not: no FU (unless MT-IPMN or family history of PDAC) |
EU, European; ACG, American College of Gastroenterology; AGA, American Gastroenterological Association; MRI, magnetic resonance imaging; CT, computer tomography; EUS, endoscopic ultrasound; FNA, fine-needle aspiration; CH-EUS, contrast-enhanced harmonic EUS; CA 19-9, cancer antigen 19-9; DM, diabetes mellitus; FU, follow-up; PDAC, pancreatic ductal adenocarcinoma; LGD, low-grade dysplasia; HGD, high-grade dysplasia
*To identify calcifications, for tumour staging or for surveillance of recurrence in case of PDAC