ASGE 2023 Masterclass EUS: Principles, Best Practices & Innovative Paradigms (On-Demand) | February 2023-Mishra_Pancreas Cysts: Everything an Endosonographer Needs to Know

Mishra_Pancreas Cysts: Everything an Endosonographer Needs to Know

Pdf Summary

Pancreatic cysts are increasingly being detected due to better quality cross-sectional imaging and an aging population. It is important for endosonographers to obtain a detailed patient history and review the imaging themselves. They should not solely rely on the imaging findings but use their endoscopic ultrasound (EUS) findings to guide their decisions. For cystic cysts, fine needle aspiration (FNA) should be performed, and for solid cysts, fine needle biopsy (FNB) should be considered. However, in some cases, EUS characteristics may be sufficient and FNA may not be necessary. It is important to discuss the potential risk of pancreatitis with FNA of pancreatic cysts. If the cyst fluid has a low carcinoembryonic antigen (CEA) level and there have been no changes on interval EUS, FNA may not be needed. Currently, antibiotics are used for cystic lesions, but this may change in the future. Cysts smaller than 1.0cm do not need to be FNA unless they are suspected to be cystic islet cell lesions. <br /><br />Differentiating between mucinous and non-mucinous cysts is important for determining the risk of malignancy. Serous cystadenomas are typically benign and can be resected for symptoms. Mucinous cystadenomas have a higher risk of malignancy and may require surgical referral. Intraductal papillary mucinous neoplasms (IPMNs) can have varying degrees of malignancy depending on their type. <br /><br />EUS imaging can help identify intracystic mucin, nodules, and determine relationships to vasculature, main duct, and resectability. However, EUS imaging alone may not be sufficient to distinguish cyst types and determine malignant risk. Cytology has a low yield and sensitivity, and cyst fluid analysis, including CEA and amylase levels, can help with diagnosis but may be insufficient for diagnosing malignancy. EUS-FNA with cyst fluid analysis has an overall accuracy of 79% for diagnosing pancreatic cysts.<br /><br />Guidelines on the management of pancreatic cystic neoplasms differ on surveillance intervals, when to stop surveillance, and when to refer patients for surgery. It is important to consider patient factors such as cyst size, classic CT/MRI findings, and patient age and surgical candidacy when deciding on the need for EUS referral. EUS-guided procedures such as cystogastrostomy and endoscopic necrosectomy have become standard treatments for pancreatic pseudocysts.<br /><br />Advancements in EUS imaging and sampling modalities, such as needle-based confocal laser endomicroscopy, are being explored to improve diagnostic yield and allow for a more accurate diagnosis of pancreatic cysts. Overall, the field of pancreatic cysts is evolving, and endosonographers need to stay up-to-date with the latest guidelines and techniques to properly manage and diagnose these lesions.

Keywords

Pancreatic cysts

endosonographers

endoscopic ultrasound

fine needle aspiration

fine needle biopsy

mucinous cysts

malignancy risk

EUS imaging

cyst fluid analysis

pancreatic cystic neoplasms