Treatment of Pancreatic Cystic Neoplasm: Surgery or Conservative? Rupjyoti Talukdar * ,‡ and D. Nageshwar Reddy* *Asian Institute of Gastroenterology, Hyderabad, India; ‡ Asian Healthcare Foundation, Hyderabad, India Pancreatic cystic neoplasms (PCNs) are a heterogeneous group of tumors with distinct biological features. These neoplasms are now being recognized more frequently owing to advances in cross-sectional imaging and increasing awareness. Guidelines for treatment of the common and clinically important PCNs frequently have been revised in view of the continuing controversies and evolving clinical data. This review summarizes the man- agement approaches of the common and clinically impor- tant PCNs based on current evidence and guidelines. Keywords: Pancreatic Cystic Neoplasm; Treatment; Surgery; Conservative. P ancreatic cystic neoplasms (PCNs) are a hetero- geneous group of tumors with distinct biological features, and can be broadly classified into epithelial and nonepithelial types. Once considered to be uncommon, these neoplasms now are being recognized more frequently as a result of advances in cross-sectional im- aging and increasing awareness. The clinically common PCNs are predominantly epithelial and the most impor- tant ones among these include serous cystadenoma (SCA), solid pseudopapillary tumor (SPT), cystic pancre- atic endocrine neoplasm (CPEN), mucinous cystic neoplasm (MCN), and intraductal papillary mucinous neoplasm (IPMN). 1 Much data have been generated on the clinical, radiologic, pathologic, malignant risk, and ge- netic aspects of PCNs over recent years. However, these appear to be far from complete as reflected by the still- existing controversies and frequent revisions of existing guidelines. The prevalence of PCNs among individuals without a history of prior pancreatic disease stands at 3% using computed tomography, but increases to 20% with magnetic resonance imaging (MRI). 2 By the age of 70, 10% of individuals have a PCN. 3 In this review, we discuss the management of the common important PCNs based on current evidence and guidelines. 2,4 Table 1 summarizes the salient features of these neoplasms and Figure 1 shows representative images. Serous Cystadenomas The overall prevalence of SCAs among resected PCNs is 16%. 1 These neoplasms can be of microcystic and oligocystic type. In view of the benign nature of SCAs, the treatment approach is determined primarily by the presence or absence of symptoms. For symptomatic SCAs, the treatment of choice is surgical resection. Even though size alone is currently not an indication for resection, large SCAs (>6 cm) of the pancreatic head were found to be an independent risk factor for aggressive behavior, and may be considered for sur- gery. 5,6 For radiologically obvious symptomatic SCAs, frozen-section biopsies are not required routinely and these patients need not undergo postoperative surveillance. 2 Surgical resection also should be considered in the radiologically SCA-like asymptomatic neoplasms in which a malignancy could not be ruled out. 7 This is especially true for the oligocystic type of SCA because it could look radiologically similar to MCNs and branch duct (BD)-IPMNs. Endoscopic ultrasound (EUS)-guided cyst fluid analysis showing less than 5 ng/mL of carci- noembryonic antigen can be of help in excluding a mucinous lesion. However, it can be difficult to obtain cyst fluid from microcystic SCAs. In lesions in which malignancy cannot be ruled out, the preferred modality of surgery is oncologic resection. 2 For the asymptomatic and surgically fit patients with SCA, follow-up evaluation should be performed initially at 3- to 6-month intervals, which subsequently can be tailored according to the growth rate of the neoplasm. 5,8 Solid Pseudopapillary Tumors SPTs are indolent and potentially malignant neo- plasms that constitute 4% of resected PCNs. 1 In view of their malignant potential, young age at onset, and excellent postoperative survival rate (5-year survival rate, 95%), surgical resection is the treatment of choice for SPTs. 6,9,10 Even though an oncologic resection generally is recommended, in view of low risk of lymph node metastasis, spleen- and pancreas-preserving Abbreviations used in this paper: BD, branch duct; CPEN, cystic pancre- atic endocrine neoplasm; EUS, endoscopic ultrasound; IPMN, intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; MD, main duct; MRI, magnetic resonance imaging; PCN, pancreatic cystic neoplasm; SCA, serous cystadenoma; SPT, solid pseudopapillary tumor. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2013.08.031 Clinical Gastroenterology and Hepatology 2014;12:145–151
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