Main target |
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Asymptomatic PCNs |
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Deals mainly with IPMN (MCN is excluded from the 2017 guideline) |
IPMN, MCN, SCA, SPEN |
IPMN, MCN, SCA, SPEN |
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Does not deal with symptomatic cysts, SPEN, MD-IPMN, etc. |
Initial image modality |
MRI preferred |
Pancreatic protocol CT or gadolinium-enhanced MRI/MRCP (Performed for cysts > 5 mm) |
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Pancreatic MRI preferred |
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MRI or MRCP preferred |
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Pancreatic protocol CT; for detection of calcification, assessment of vascular involvement, peritoneal or metastatic disease, or suspicion of malignant PCNs |
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Pancreatic protocol CT or EUS-for patients who are unable to undergo MRI |
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EUS-FNA for cysts where the diagnosis is unclear |
Indications of EUS ± FNA |
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PCNs with at least two high-risk features |
Presence of any “worrisome features” |
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Adjunct to other imaging modalities |
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Patients who are unable to undergo MRI |
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EUS-FNA: only be performed when the results are expected to change clinical management |
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EUS-FNA and fluid analysis for cysts in which the diagnosis is unclear, and where the results are likely to alter management |
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Significant changes in characteristics of the cyst |
High-risk features |
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Cyst size ≥ 3 cm |
IPMN |
IPMN |
IPMN, MCN |
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Dilated MPD |
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“worrisome features” |
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Relative indications for surgery |
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New-onset or worsening diabetes mellitus |
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Presence of an associated solid component |
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Pancreatitis |
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Grow-rate ≥ 5 mm/year |
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Cyst size > 3 cm |
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Increased levels of serum CA 19-9 |
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Rapid increase in cyst size (of > 3 mm/year) during surveillance |
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Enhancing mural nodule < 5 mm |
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MPD dilatation between 5 and 9.9 mm |
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Recommendation: short-interval MRI or EUS ± FNA |
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Indication for surgery |
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Thickened/enhancing cyst walls |
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Cyst diameter ≥ 40 mm |
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Patients with both a solid component and a dilated pancreatic duct |
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MPD size 5-9 mm |
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New onset of diabetes mellitus |
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Abrupt change in caliber of MPD with distal pancreatic atrophy |
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Acute pancreatitis (caused by IPMN) |
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Concerning features on EUS and FNA (e.g., positive cytology on EUS-guided FNA) |
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Enhancing mural nodule (< 5 mm) |
High-risk characteristics for mucinous pancreatic cysts |
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Lymphadenopathy |
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Increased serum level of CA 19-9 |
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Absolute indications for surgery |
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Jaundice secondary to the cyst |
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Cyst growth rate > 5 mm/2 years |
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Positive cytology for malignancy/HGD |
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Acute pancreatitis secondary to the cyst |
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Elevated serum CA 19-9 where no benign cause for elevation is present |
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“High-risk stigmata” |
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Solid mass |
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Obstructive jaundice in a patient with cystic lesion of the head of the pancreas |
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Jaundice (tumor-related) |
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Mural nodule or solid component within the cyst or pancreatic parenchyma |
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Enhancing mural nodule (≥ 5 mm) |
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MPD dilatation ≥ 10 mm |
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MPD diameter of >5 mm/change in MPD caliber with upstream atrophy |
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Enhancing mural nodule > 5 mm |
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MPD > 10 mm |
MCN |
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Size > 3 cm |
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Cyst size ≥ 40 mm |
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Increase in cyst size > 3 mm/year |
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MCN (IAP 2012 guideline) |
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Symptomatic |
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HGD or pancreatic cancer on cytology Recommendation: undergo EUS ± FNA and/or be referred to a multidisciplinary group |
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Surgical resection recommended for all surgically fit patients |
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Presence of risk factor (e.g., mural nodule) |
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Observation may be considered in elderly frail patients with MCNs of < 4 cm without mural nodules |
Indication of surveillance |
Pancreatic cysts <3 cm without a solid component or a dilated pancreatic duct |
PCN size < 3 cm, without high-risk features |
IPMN, MCN |
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Surgically fit + asymptomatic, presumed to be IPMNs or MCNs |
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Cyst size < 40 mm without a mural nodule or symptoms |
Surveillance methods and intervals |
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MRI preferred. |
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MRCP and/or EUS, with type and timing depending on cyst size/features |
IPMN, MCN |
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MRI preferred |
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After 1 year, then every 2 years for a total of 5 years (if there is no change in size or characteristics) |
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MRI and/or EUS, CA19-9 |
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Type and timing depending on cyst size/features |
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Every 6 months for 1 year |
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Yearly after first year |
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Every 6 months for relative indication for surgery |
Discontinuation of surveillance |
If there is no change in size or characteristics for a total of 5 years |
Lifelong surveillance |
Lifelong surveillance until the patient is no longer fit for surgery |
Lifelong surveillance until the patient is no longer fit for surgery |
Surveillance after resection |
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Cysts with invasive cancer or dysplasia in a cyst: MRI every 2 years. |
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Family history of PDAC / a surgical margin positive for HGD / non-intestinal subtype of resected IPMN - Cross-sectional imaging at least twice a year |
IPMN, MCN |
SCN, pseudocyst, MCN without pancreatic cancer surveillance not recommended. |
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Invasive carcinoma - same manner as those with a resected pancreatic cancer |
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Cysts without HGD or malignancy: routine surveillance not recommended. |
IPMN |
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HGD or MD-IPMN - every 6 months for the first 2 years, followed by yearly |
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surveillance needed |
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Others: Cross-sectional imaging every 6-12 months |
SPEN |
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LGD - same manner as non-resected IPMN |
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followed on a yearly basis for at least 5 years |
SPEN |
Not mentioned |
Not mentioned |
Radical resection for all patients |
Referred to a multidisciplinary group for consideration of surgical resection |
SCN |
Not mentioned |
Not mentioned |
Followed up for 1 year, and symptom-based follow-up thereafter. |
No follow-up recommended if asymptomatic |