Original
Prevalence of incidental clinically relevant pancreatic cysts at diagnosis based on current guidelinesPrevalencia de quistes pancreáticos incidentales clínicamente relevantes al momento del diagnóstico basada en las guías actuales

https://doi.org/10.1016/j.gastrohep.2017.12.005Get rights and content

Abstract

Background

Most pancreatic cysts (PCs) found incidentally by CT and MRI scans might not be clinically important according to the Fukuoka guidelines, the American Gastroenterological Association (AGA) guidelines and European guidelines.

Aims

To determine and compare the prevalence of incidental clinically important PCs (CIPCs).

Methods

Abdominal contrast-enhanced CT or MRI scans performed during a one-year period were retrospectively reviewed to identify incidental PCs. CIPCs were defined as those cysts that would be capable of triggering further evaluation with endoscopic ultrasound, immediate surveillance (within 3–6 months) and/or surgery. Prevalence was calculated as the number of patients with CIPCs per 100 subjects imaged (%).

Results

Sixty patients (mean age 70±14 years) out of 565 were found to have incidental PCs, representing a prevalence of 8.7% (95% CI 6.3–11.5) in CT scans and 27.5% (95% CI 16–41) in MRI scans. Seven patients (11.6%, 95% CI 5–22) had CIPCs based on size ≥ 30 mm (n=5), size ≥ 30 mm and pancreatic duct (PD) dilation (n=1) and PD dilation and presence of solid component (n=1). Based on the Fukuoka guidelines, the prevalence of CIPCs was 1.2% (95% CI 0.4–2.5) in CT scans (6/507) and 1.7% (95% CI 0.1–9) in MRI scans (1/58). Based on the AGA and European guidelines, the prevalence of CIPCs was 0.2% (95% CI 0.1–1) in CT scans (1/507) and 1.7% (95% CI 0.1–9) in MRI scans (1/58). Patients with PCs initially classified as “AGA- or European-positive” had a higher surgical probability and this decision was taken earlier in the follow-up.

Conclusions

In our cohort, the prevalence of important incidental pancreatic cysts was not negligible at around 1% according to current guidelines.

Resumen

Antecedentes

La mayoría de los quistes de páncreas (PC) hallados incidentalmente en las tomografías (TC) y las resonancias magnéticas (RMN) podrían no ser clínicamente importantes de acuerdo con las actuales guías Fukuoka, American Gastroenterological Association (AGA) y europea.

Objetivos

Determinar y comparar la prevalencia de PC incidentales clínicamente importantes (CIPCs).

Métodos

Se revisaron retrospectivamente las TC de abdomen con contraste y las RMN durante un período de un año para identificar PCs incidentales. Los CIPC se definieron como aquellos quistes que serían capaces de desencadenar una evaluación ulterior con ecoendoscopia, vigilancia en un corto intervalo (3-6 meses) y/o cirugía. La prevalencia se calculó como el número de pacientes con CIPC por cada 100 sujetos estudiados (%).

Resultados

Se encontró que 60 (edad media 70 ± 14 años) de 565 pacientes tenían PC incidentales, lo que representó una prevalencia de 8,7% (IC95% 6,3-11,5) en las TC y 27,5% (IC95% 16-41) en las RMN. Siete pacientes (11,6%, IC95% 5-22) tenían CIPC basados en el tamaño ≥30 mm (n=5), tamaño ≥30 mm y dilatación del conducto pancreático (PD) (n=1), y dilatación de PD y presencia de componente sólido (n=1). Basándonos en la guía Fukuoka, la prevalencia de CIPC fue de 1,2% (IC95% 0,4-2,5) en las TC (6/507) y 1,7% (IC95% 0,1-9) en las RMN (1/58). Basado en las guías AGA y europea, la prevalencia de CIPC fue de 0,2% (IC95% 0,1-1) en las TC (1/507) y 1,7% (IC95% 0,1-9) en las RMN (1/58). Los pacientes con PC inicialmente clasificados como “AGA o europea positivo” tuvieron una mayor probabilidad quirúrgica y esta decisión se tomó antes en el seguimiento.

Conclusiones

En nuestra cohorte, la prevalencia de quistes pancreáticos incidentales y relevantes no fue despreciable, siendo cercana al 1% según las guías actuales.

Introduction

Most pancreatic cysts (PCs) are found incidentally in cross sectional imaging. Current high-resolution computed tomography (CT) and magnetic resonance imaging (MRI) allow identification of PCs in patients imaged for diseases unrelated to the pancreas, and its prevalence is supposed to be between 2-20% depending on patient's age and type of scan.1, 2, 3

PCs are considered to be a risk factor for pancreatic cancer which is difficult to detect in early stages. In addition, incidental PCs are associated with an increased risk of adenocarcinoma that would be three time higher than controls.4

Although the clinical behavior of the PCs is uncertain and controversial, most of these incidental pancreatic cystic lesions might not be clinically important according to the most common guidelines currently used: the Fukuoka guideline,5 the American Gastroenterological Association (AGA) guideline,6 and the European guideline.7

In 2013, the European experts consensus statement7 established that the presence of symptoms related to the pancreas, mural nodules, dilation of the main pancreatic duct > 6 mm, cyst rapidly increasing in size, or elevated serum levels of carbohydrate antigen (CA)19-9 were risk factors for the presence of malignancy in branch duct-intraductal papillary mucinous neoplasias.

In 2015, the AGA guideline6 defined that asymptomatic patients with PCs should have at least two high risk features (size greater than 30 mm, dilation of the main pancreatic duct, or solid component) in order to consider them as having relevant alert signs, and recommended further evaluation in the short term or surgery only in this subgroup of patients.

In 2017, the Fukuoka guideline5 was reviewed and updated; it defined the “worrisome features” (cyst size ≥3 cm, thickened/enhancing cyst walls, main pancreatic duct size between 5-9 mm, enhancing mural nodule < 5 mm, abrupt change in caliber of pancreatic duct with distal pancreatic atrophy, lymphadenopathy, elevated serum level of CA 19-9, and rapid rate of cyst growth > 5 mm/2 years) and the “high risk stigmata” (obstructive jaundice, enhanced mural nodule ≥ 5 mm, main pancreatic duct ≥10 mm) as important features in patients with mucinous PCs, and recommended further evaluation (endoscopic ultrasound with fine needle aspiration (EUS-FNA) and surveillance in a short interval with MRI or CT scan) or surgery in patients with at least one of these features.

The presence of any cystic lesion in the pancreas causes concern and anxiety in patients, especially if the characteristics of the lesion demand more evaluations and procedures. Many studies have evaluated the accuracy of these guidelines8, 9 to detect advanced lesions and minimally invasive cancer. Considering that these guidelines have different criteria to define the importance of the cystic lesions, the prevalence of relevant or clinically important PCs (CIPCs) at the time of the diagnosis might be different depending on the guideline used.

Therefore, our aims were to assess the prevalence of PCs in a cohort of consecutive adults undergoing cross-sectional imaging (CT or MRI) for non-pancreatic reasons in a community hospital, and to determine and compare the prevalence of incidental CIPCs among these three guidelines (Fukuoka,5 AGA,6 and European7) at the time of the diagnosis.

Section snippets

Methods

The study protocol was approved by the human ethics committee from our institution. Our institutional review board approved the review of radiological and clinical data for this study. Informed consent was waived for this retrospective review study.

An extensive and broad search was performed to identify patients with abdominal contrast enhanced-CT or MRI scans in the Radiology Department database. All reports of patients with abdominal contrast enhanced-CT or abdominal MRI scans (with or

Results

After searching in the Radiology Department database (Figure 1), 1238 potential patients were analyzed during this 12-month period. Six hundred seventy-three patients were excluded because of non-contrast enhanced abdominal CT scan (n 588), indications related to the pancreas (n 55, mostly pancreatitis and surveillance of pancreatic cysts), or abdominal ultrasounds showing PCs or suspicious of PCs prior to the scan (n 30). Finally, five hundred sixty-five patients fulfilled the inclusion

Discussion

Most patients with PCs are referred because of an incidental finding in a CT or MRI. Nowadays, it is relatively frequent to find PCs incidentally due to the current high-resolution cross-sectional images. The finding of PCs in an asymptomatic patient represents an immediate challenge to the radiologist and the clinician.1 PCs have variable potential malignancy and this is a source of discomfort for many physicians. Differentiating which PCs are or could be malignant is the key question. The

CONCLUSIONS

The prevalence of relevant incidental pancreatic cyst is not negligible according to current guidelines. In our cohort it was close to 1%, being slightly higher using the Fukuoka criteria. PCs that were initially cataloged as “Fukuoka, AGA and European negative” remained stable without changes during the follow-up. Only 11.6% (95%CI, 5-22) of the patients with PCs were considered to have CIPCs (7/60). Patients with PCs initially classified as AGA or European positive had a higher surgical

Institution

Gastroenterology and Endoscopy Unit, Internal Medicine Department, Hospital Alemán, Av. Pueyrredón 1640, CABA, CP 1118, Buenos Aires, Argentina

Author contributions

All the authors solely contributed to this paper, helping to conduct the study, analyzing the data and writing the manuscript.

Supportive foundations

Authors declared that there isńt any supportive foundation.

Institutional review board statement

The human ethics committee from our institution approved the protocol. Our hospital institutional review board approved the review of radiological and clinical data for this study. Informed consent was waived for this retrospective review study.

Informed consent statement

Informed consent was waived for this retrospective review study.

Conflict-of-interest statement

All the Authors have no conflict of interest related to the manuscript.

Data sharing statement

The original anonymous dataset is available on request from the corresponding author at [email protected]

Acknowledgements

All authors approved the final version of the manuscript. Authors declared that there isńt any supportive foundation. Authors have no conflict of interest related to the manuscript.

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