ASGE 2023 Masterclass EUS: Principles, Best Practices & Innovative Paradigms (Virtual) | 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 being increasingly detected in asymptomatic patients through cross-sectional imaging. It is important for endosonographers to obtain a detailed history and review the imaging themselves. While cross-sectional imaging can provide some information about the cyst, it is essential to use endoscopic ultrasound (EUS) findings to guide further diagnosis. Fine needle aspiration (FNA) of the cystic portion and fine needle biopsy (FNB) of the solid portion may be performed, but it is not always necessary to perform FNA as EUS characteristics can be sufficient. Endosonographers should also discuss the potential for pancreatitis with FNA of pancreatic cysts.<br /><br />For cysts less than 1.0cm, FNA may not be needed unless it is suspected to be a cystic islet cell lesion. Aspirating the cyst completely is recommended, and if only enough fluid is available for one test, considering CEA/glucose testing can be useful.<br /><br />Differentiating between mucinous and non-mucinous cysts is important in determining malignant risk. Serous cystadenoma (SCN) is a benign tumor with no malignant potential, while mucinous cystadenoma (MCN) has a prevalence of malignancy of about 15%. Both main duct and branch duct intraductal papillary mucinous neoplasms (IPMN) have malignancy potential, with main duct IPMN having a higher prevalence of malignancy (up to 40%). Solid pseudopapillary neoplasm (SPN) is a low-grade malignant neoplasm that occurs in young women.<br /><br />EUS imaging can help identify intracystic mucin, nodules, and determine the relationship to vasculature and main duct. However, EUS imaging alone is often inadequate to distinguish cyst types and malignant risk. Therefore, cyst fluid analysis is crucial, including cytology, chemical analysis (CEA, amylase), and DNA analysis. EUS-FNA with cyst fluid analysis has an overall accuracy of 79%, but CEA alone is insufficient for diagnosing malignancy.<br /><br />There are different guidelines for managing pancreatic cystic neoplasms, including surveillance intervals, when to stop surveillance, and when to refer patients to surgery. EUS-guided interventions, such as cystogastrostomy and necrosectomy, provide less invasive options for treatment.<br /><br />The use of novel techniques like EUS-guided cystoscopy and needle-based confocal laser endomicroscopy (nCLE) are being explored for improving diagnostic yield and better characterizing pancreatic cysts in the future.

Keywords

Pancreatic cysts

cross-sectional imaging

endoscopic ultrasound

fine needle aspiration

mucinous cysts

malignant risk

EUS imaging

cyst fluid analysis

guidelines for managing pancreatic cystic neoplasms

novel techniques