Update: Pancreatic Cystic Neoplasms

According to the American Cancer Society, the incidence of pancreatic cancer in the United States has increased about 1.5% per year since 2004. The most recent estimates for 2012:

  • About 43,920 people (22,090 men and 21,830 women) will be diagnosed with pancreatic cancer.
  • About 37,390 people (18,850 men and 18,540 women) will die of pancreatic cancer.

This deadly disease is particularly difficult to treat because detection has been such a challenge.

Clinical Manifestations

Patients with pancreatic cysts are typically asymptomatic or present with nonspecific symptoms. However, as widespread use of cross-sectional imaging has increased, so has the detection of pancreatic cysts. Today, many cysts are being discovered coincidentally when abdominal imaging is performed for unrelated indications—currently appearing in 1.2% of abdominal imaging with CT or MRI.

Pancreatic cysts are classified as neoplastic or non-neoplastic. Accurate cyst categorization is important, since non-neoplastic cysts require treatment only if symptomatic, whereas some of the pancreatic cystic neoplasms have significant malignant potential and should be resected.

Types of Pancreatic Cystic Neoplasms (PCNs)

PCNs account for more than 50 percent of pancreatic cysts, even in patients with a history of pancreatitis. PCNs are categorized using the WHO histological classification. There are four subtypes of PCNs that have varying malignant potential:

  • Serous cystic tumors
  • Mucinous cystic neoplasms
  • Intraductal papillary mucinous neoplasms
  • Solid pseudopapillary neoplasms

There is little to no malignant potential with serous cystadenomas.

Evaluation

The major challenge in the evaluation of PCNs is identifying lesions with malignant potential. Both symptomatic and asymptomatic pancreatic cysts require evaluation, even in patients who have had pancreatitis. Some PCNs can cause pancreatitis, and more than half of cysts in patients with pancreatitis are PCNs.

If a cyst is less than 5mm in largest diameter, asymptomatic and lacks concerning features on imaging (e.g. mural nodularity), it is reasonable to repeat cross-sectional imaging in one year.

Additional evaluation (e.g. endoscopic ultrasound) is required for most other cysts and for patients with small cysts who develop symptoms or cyst enlargement.

Endoscopic ultrasound — EUS provides high quality imaging of the pancreas, as well as the opportunity to sample pancreatic lesions through fine-needle aspiration (EUS-FNA), which significantly increases diagnostic accuracy.

Tumor markers — Carcinoembryonic antigen (CEA) is the best-studied and most accurate tumor marker for diagnosing a mucinous PCN, although the accuracy and the cut-off level vary among laboratories. Approximately 0.2 to 1.0 mL of cystic fluid is required to run the test.

Molecular markers — Molecular markers and cyst fluid DNA are other methods used to differentiate mucinous PCNs from nonmucinous.

Diagnosis and Treatment

The most advanced, state-of-the-art care for pancreatic conditions is available right here in Northern Virginia at Inova Fairfax Hospital’s Center for Advanced Endoscopy. The Center is led by a team of board-certified therapeutic endoscopists, including GANV physicians, Dr. Bezhad Kalaghchi, Medical Director, and Dr. Byungki Kim, Co-Director.

Procedures performed at the Center include:

Benign Pancreaticobiliary Disease:

– Sphincter of Oddi manometry
– EUS-guided pancreatic pseudocyst drainage
– ERCP with cholangioscopy and mechanical lithotripsy
– Pancreatic endotherapy

Pancreaticobiliary Neoplasia:

– EUS-FNA for diagnosis and staging of pancreatic solid and cystic lesions
– EUS-guided celiac plexus neurolysis for chronic pancreatitis and pancreatic cancer
– Endoscopic ampullectomy
– Endoscopic duodenal stenting
– EUS staging

Collaborative Care

To ensure each patient receives timely, appropriate and exceptional care, we employ a collaborative approach. Our physicians work with a multidisciplinary team of specialists in radiology, pathology, surgery, medical and radiation oncology. Referring physicians are considered integral members of the team and encouraged to remain involved.

Making a Referral

When you refer a patient to our care, we keep you updated by providing detailed reports, arranging follow-up sessions with you and being accessible for questions and discussions. You will be well informed when the patient is returned to your care.

If you are unsure how to manage a particular patient and would like a brief discussion before making a referral, please call 703-698-8960 and ask to speak to Dr. Behzad Kalaghchi or Dr. Byungki Kim. They will be happy to answer your questions and offer their recommendation.

To refer patients, please ask them to call 703-698-8960 and request an appointment with either Dr. Kalaghchi or Dr. Kim.

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