Revised international consensus guidelines for the management of patients with mucinous cysts

Abstract

The management of patients with pancreatic cysts is a significant issue in the health care community. We know from over 30 years of study that mucinous cysts account for a significant percentage of pancreatic cysts, and that mucinous cysts are precursors of pancreatic carcinoma. Based on autopsy studies, approximately 2.6% of the adult population and nearly 8% of elderly patients have a pancreatic cyst.1 How many of these cysts are mucinous and, of those that are mucinous, how many are malignant or sufficiently highgrade to prompt surgical management is a conundrum physicians are facing on an increasingly common basis. 2,3 The detection of mucinous cysts before the development of invasive carcinoma is the goal of management given that invasion is the single most important factor determining patient prognosis. 4Understanding the clinicopathological features of pancreatic cysts is critical in answering the important question of whether surgical management is warranted, and this requires a multidisciplinary approach. 5,6In 2005, an international and multidisciplinary group of physicians met in Sendai, Japan and developed a consensus document to guide physicians in the diagnosis and management of patients with pancreatic mucinous cysts (also known as the ''Sendai guidelines''). 7 In brief, these guidelines called for the conservative management of asymptomatic patients with pancreatic mucinous cysts that were small (< 3 cm), not associated with a dilated main pancreatic duct (MPD) ( 6 mm) or mural nodule by imaging, and without ''positive cytology.'' Since their publication in 2006, studies have shown the Sendai guidelines to be highly sensitive (approximately 97%), but very nonspecific (approximately 29%) for the detection of a malignant mucinous cyst. [8][9][10] Cyst size and nonspecific patient symptoms have proven to be poor predictors of malignancy. 11,12 Although the majority of patients with cancer were detected, many patients already had invasive cancers at the time of surgical resection. In addition, many elderly patients with significant comorbid conditions and mucinous cysts with low-to intermediate-grade (moderate) dysplasia were also undergoing surgical resection, which is riskier than conservative follow-up because the progression to carcinoma would likely take longer than the expected life expectancy of the patient. Most importantly, some asymptomatic patients with carcinoma or high-grade dysplasia but with no high-risk imaging features were being followed conservatively. 12,13In 2010, a new international, multidisciplinary group of physicians (the 8 members of the original group plus 6 new physicians from various specialties) met in Fukuoka, Japan to revisit the Sendai guidelines and to discuss advances in the understanding of the biology, imaging, preoperative testing, and surgical management of patients with mucinous cysts, with the goal of providing a revised management algorithm.14 Because the levels

EUS‐FNA diagnosis of pancreatic serous cystadenoma with the aid of cell blocks and α‐inhibin immunochemistry: A case series

“…15,16 Preoperative multimodal approach of pancreatic cystic lesions (radiology; cystic fluid biochemistry; cytology) is useful for two reasons: first, to distinguish between non-mucinous (eg, pseudocyst, SCA) and mucinous cysts (intraductal papillary mucinous neoplasm, IPMN; mucinous cystic neoplasm, MCN); second, to assess the risk of malignancy by identifying high-risk mucinous cysts that would benefit the most from a potential surgery. [16][17][18][19] Measurement of CEA levels in the pancreatic cystic fluid is the best way to separate mucinous from non-mucinous cysts and is found to perform better than cytology itself. [20][21][22] Nonmucinous cysts are generally found to have low CEA levels (<5 ng/mL in most SCAs) in contrast to mucinous cysts (>192 ng/mL).…”

Pancreatic fine-needle aspiration cytopathology: an analysis of the CAP NGC program for pancreatic FNA 2003–2011

“…[11][12][13][14][15] Evolution in the terminology of the CAP NGC program in pancreatobiliary cytopathology will be developed in the spirit of recent efforts by Pitman (Massachusetts General Hospital, Boston, Mass) and Layfield (University of Missouri, Columbia, Mo) who recently published a set of cytopathology guidelines under the auspices of the Papanicolaou Society. 16 Table 1 exhibits terminology used during the study period and compares it to the new proposed terminology of the pancreatobiliary cytology guideline study group.…”

Post-brushing and fine-needle aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The Papanicolaou Society of Cytopathology Guidelines

“…The Fukuoka revised guidelines for management of mucinous cystic neoplasms and intraductal papillary mucinous neoplasms[4548]…”