Table 1.
Possible indications for surgery, diagnostic techniques and management according to the International, European and American Gastroenterological Association (AGA) guidelines.
| Guideline | Year | Possible indications for surgery | Diagnostic technique | Management |
|---|---|---|---|---|
| IAP I27 | 2006 | Symptoms Cyst size ≥3 cm Mural nodule MPD ≥5 mm Positive cytology | CT scan MRI/MRCP EUS + FNA | Surgery |
| AGA8 | 2015 | High risk features: - Cyst size ≥3 cm - Presence of solid component - Dilated MPD - HGD or cancer on cytology | (CT scan) MRI/MRCP EUS + FNA | Surgery |
| IAP III6,a | 2017 | High risk stigmata - Jaundice - Enhancing mural nodule ≥5 mm - MPD ≥10 mm - HGD or cancer on cytology Worrisome features - Cyst size ≥3 cm - Acute pancreatitis (due to IPMN) - Enhancing mural nodule <5 mm - Thickened and enhancing cyst wall - MPD dilation 5–9 mm - Abrupt change of MPD calibre with distal pancreatic atrophy - Presence of lymphadenopathy - Elevated serum CA 19–9 - Cyst growth rate >5 mm/2 years | (CT scan) MRI/MRCP (CT scan) MRI/MRCP EUS + FNA: required after imaging | Surgery Surgery versus close surveillance based on: • Patients’ age/comorbidities: more aggressive management (surgery) in young patients • EUS findings: surgery indicated in clear MPD involvement and/or high-risk features |
| European7 | 2018 | Absolute indications - Jaundice - Enhancing mural nodule ≥5 mm - MPD ≥10 mm - HGD or cancer on cytology - Solid mass Relative indications - Cyst size ≥4 cm - Enhancing mural nodule <5 mm - MPD dilation 5–9.9 mm - Serum CA 19.9 ≥37 U/ml - Cyst growth rate >5 mm/years - Acute pancreatitis (due to IPMN) - New onset of diabetes | (CT scan) (EUS + FNA) MRI/MRCP (CT scan) (EUS + FNA) MRI/MRCP | Surgery Surgery • In fit patients surgery for ≥1 criterion • In patients with significant comorbidities surgery for ≥2 criteria |
CT: computed tomography; EUS: endoscopic ultrasound; FNA: fine needle aspiration; HGD: high-grade dysplasia; IAP: International Association of Pancreatology; IPMN: intraductal papillary mucinous neoplasm; MPD: main pancreatic duct; MRCP: magnetic resonance with cholangiopancreatography; MRI: magnetic resonance imaging.
A second revision of the International guidelines was made in 2012; since the guidelines did not change significantly – particularly when considering indications for surgery/surveillance – the last and updated version of the International guidelines has been included in this review.