Guideline sources The following summarized guidelines for the evaluation and management of neoplastic pancreatic cysts are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2020), the American College of Gastroenterology (ACG 2018), the American Society for Gastrointestinal Endoscopy (ASGE 2016), and the American Gastroenterological Association (AGA 2015). 1 2 3 4 Guidelines 1. Screening and diagnosis Clinical manifestations: be cautious when attributing symptoms to pancreatic cyst, recognizing that the majority of pancreatic cysts are asymptomatic and the non-specific nature of symptoms requires clinical discernment. B 2. Diagnostic investigations https://web.pathway.md/diseases/recbaKboAjbO4rJ5q 1/5 6/30/23, 1:16 AM Neoplastic pancreatic cysts Pathway Diagnostic imaging: As per ACR 2020 guidelines, obtain abdominal MRI without and with IV contrast with MRCP for initial evaluation of patients with an incidentally detected pancreatic cyst 2.5 cm in size or > 2.5 cm in size but with no high-risk stigmata or worrisome features. B Show 2 more As per ACG 2018 guidelines, obtain MRI or MRCP as the test of choice because of their noninvasiveness, lack of radiation and greater accuracy in assessing communication between the main pancreatic duct and the cyst, which is a characteristic of side-branch intraductal papillary mucinous neoplasms. B Show 2 more As per ASGE 2016 guidelines, consider obtaining the following investigations for the diagnosis and characterization of suspected main duct intraductal papillary mucinous neoplasms: ERCP pancreatoscopy intraductal ultrasound. C Further evaluation: Do not obtain further evaluation of incidentally found pancreatic cysts in patients not medically fit for surgery, irrespective of cyst size. D Do not obtain further evaluation in patients with asymptomatic cysts diagnosed as pseudocysts on initial imaging and clinical history or having very low risk of malignant transformation (such as serous cystadenomas). D 3. Diagnostic procedures Fine needle aspiration: As per ACG 2018 guidelines, perform EUS with or without FNA and/or refer to a multidisciplinary pancreatic group for further evaluation in patients with intraductal papillary mucinous neoplasms or mucinous cystic neoplasms with any of the following features: Situation Guidance Jaundice secondary to the cyst Symptoms or signs Acute pancreatitis secondary to the cyst Significantly elevated serum CA 19-9 The presence of a mural nodule or solid component either within the cyst or in the pancreatic parenchyma Imaging findings Dilation of the main pancreatic duct of > 5 mm https://web.pathway.md/diseases/recbaKboAjbO4rJ5q 2/5 6/30/23, 1:16 AM Neoplastic pancreatic cysts Pathway A focal dilation of the pancreatic duct concerning for main duct intraductal papillary mucinous neoplasms or an obstructing lesion Intraductal papillary mucinous neoplasms and mucinous cystic neoplasms measuring 3 cm in diameter High-grade dysplasia Cytologic findings Pancreatic cancer. B As per ASGE 2016 guidelines, perform EUS-guided FNA of any pancreatic cystic lesion > 3 cm in diameter or when cross-sectional or EUS confirms an epithelial nodule, dilated main pancreatic duct, or suspicious mass lesion. B Show 2 more As per AGA 2015 guidelines: Consider performing EUS-FNA in patients with pancreatic cysts with at least 2 high-risk features, such as size 3 cm, a dilated main pancreatic duct, or the presence of an associated solid component. C Consider performing EUS-FNA in patients with significant changes in the characteristics of the cyst, including the development of a solid component, increasing size of the pancreatic duct, and/or diameter 3 cm. C Cyst fluid analysis: As per ACG 2018 guidelines, consider performing EUS-guided FNA and obtaining cyst fluid analysis of cysts in which the diagnosis is unclear, and if the results are likely to alter management. C Show 4 more As per ASGE 2016 guidelines: Obtain initial testing of aspirated pancreatic cyst fluid for CEA, amylase, and cytology. B Consider obtaining molecular testing of the cyst if initial ancillary testing of cytology and CEA is inconclusive and when test results may alter management. C 4. Surgical interventions Surgical resection: As per ACG 2018 guidelines, refer patients with a solid-pseudopapillary neoplasm to a multidisciplinary group for consideration of surgical resection. B As per AGA 2015 guidelines: Refer patients with a pancreatic cyst being candidates for surgery to a center with demonstrated expertise in pancreatic surgery. B https://web.pathway.md/diseases/recbaKboAjbO4rJ5q 3/5 6/30/23, 1:16 AM Neoplastic pancreatic cysts Pathway Consider performing surgery in patients with both a solid component and a dilated pancreatic duct and/or concerning features on EUS and FNA to reduce the risk of mortality from carcinoma. C 5. Patient education General counseling: ensure that patients have a clear understanding of programmatic risks and benefits before starting any pancreatic cyst surveillance program. 6. Follow-up and surveillance Surveillance imaging: As per ACR 2020 guidelines, obtain the following investigations for the follow-up imaging in patients with pancreatic cyst: abdominal CT with IV contrast multiphase abdominal MRI without and with IV contrast with MRCP abdominal MRI without IV contrast with MRCP. B As per ACG 2018 guidelines, obtain cyst surveillance in surgically fit patients with asymptomatic cysts presumed to be intraductal papillary mucinous neoplasms or mucinous cystic neoplasms. B Show 6 more As per AGA 2015 guidelines, consider obtaining MRI surveillance in 1 year in patients with pancreatic cysts < 3 cm without a solid component or a dilated pancreatic duct, and then every 2 years for a total of 5 years if there is no change in size or characteristics. C Show 2 more Postsurgical surveillance: As per ACG 2018 guidelines, do not follow-up patients with a surgically resected serous cystadenomas, pseudocyst or other benign cyst. D Show 3 more As per AGA 2015 guidelines: Consider obtaining MRI surveillance of any remaining pancreas every 2 years in patients with surgically resected invasive cancer or dysplasia in a cyst. C Consider avoiding obtaining routine surveillance of pancreatic cysts without high-grade dysplasia or malignancy at surgical resection. D Clinical findings Symptoms Past medical history Abdominal pain Acute pancreatitis https://web.pathway.md/diseases/recbaKboAjbO4rJ5q 4/5 6/30/23, 1:16 AM Neoplastic pancreatic cysts Pathway Back pain Lab findings Postprandial fullness Weight loss serum CA 19-9 Integument exam Jaundice Imaging findings Pancreatic cyst Pancreatic duct dilatation Studies 2023 Antimicrobial prophylaxis in pancreatoduodenectomy In adults undergoing open pancreatoduodenectomy for any indication, piperacillin-tazobactam was superior to cefoxitin with respect to the rate of postoperative surgical site infection within 30 days. Michael I D'Angelica et al. JAMA. 2023 May 9. References 1. Expert Panel on Gastrointestinal Imaging, Kelly F brega-Foster, Ihab R Kamel et al. ACR Appropriateness Criteria Pancreatic Cyst. J Am Coll Radiol. 2020 May;17 5S S198 S206. Open 2. Vege SS, Ziring B, Jain R et al. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 2015 Apr;148 4 819 22. Open 3. Grace H Elta, Brintha K Enestvedt, Bryan G Sauer et al. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol. 2018 Apr;113 4 464 479. Open 4. ASGE Standards of Practice Committee, V Raman Muthusamy, Vinay Chandrasekhara et al. The role of endoscopy in the diagnosis and treatment of cystic pancreatic neoplasms. Gastrointest Endosc. 2016 Jul;84 1 1 9. Open https://web.pathway.md/diseases/recbaKboAjbO4rJ5q 5/5