Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 14, 2019; 25(18): 2217-2228
Published online May 14, 2019. doi: 10.3748/wjg.v25.i18.2217
Role of abdominal ultrasound for the surveillance follow-up of pancreatic cystic neoplasms: a cost-effective safe alternative to the routine use of magnetic resonance imaging
Luca Morelli, Simone Guadagni, Valerio Borrelli, Roberta Pisano, Gregorio Di Franco, Matteo Palmeri, Niccolò Furbetta, Dario Gambaccini, Santino Marchi, Piero Boraschi, Luca Bastiani, Alessandro Campatelli, Franco Mosca, Giulio Di Candio
Luca Morelli, Simone Guadagni, Gregorio Di Franco, Matteo Palmeri, Niccolò Furbetta, Giulio Di Candio, General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
Luca Morelli, Franco Mosca, EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa 56124, Italy
Valerio Borrelli, Roberta Pisano, Alessandro Campatelli, Diagnostic and Interventional Ultrasound in Transplants Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
Dario Gambaccini, Santino Marchi, Gastroenterology Unit, University of Pisa, Pisa 56124, Italy
Piero Boraschi, 2nd Radiology Unit, Department of Diagnostic Imaging, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
Luca Bastiani, Institute of Clinical Physiology, National Council of Research, Pisa 56124, Italy
Author contributions: Morelli L, Guadagni S, Di Franco G, Palmeri M, Furbetta N, Marchi S, Boraschi P, Mosca F and Di Candio G designed research; Morelli L, Guadagni S, Borrelli V, Pisano R, Furbetta N, Gambaccini D, Bastiani L, Campatelli A and Di Candio G performed research; Morelli L, Palmeri M, Di Franco G and Bastiani L analyzed data; Morelli L, Guadagni S, Borrelli V, Pisano R, Di Franco G, Palmeri M, Furbetta N, Gambaccini D, Marchi S, Boraschi P, Campatelli A, Mosca F and Di Candio G wrote the paper.
Institutional review board statement: The study was approved by Ethics committee of “Area Vasta Nord Ovest (CEAVNO)”.
Informed consent statement: All patients signed an informed consent to authorize the scientific use of the collected data.
Conflict-of-interest statement: No conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Luca Morelli, MD, FACS, Associate Professor, General Surgery Unit, Department of Surgery, Translation and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa 56124, Italy.
Telephone: +39-50-995470 Fax: +39-50-996985
Received: December 13, 2018
Peer-review started: December 13, 2018
First decision: December 28, 2018
Revised: January 27, 2019
Accepted: January 28, 2019
Article in press: January 28, 2019
Published online: May 14, 2019

Patients with pancreatic cystic neoplasms (PCN), without surgical indication at the time of diagnosis according to current guidelines, require lifetime image-based surveillance follow-up. In these patients, the current European evidenced-based guidelines advise magnetic resonance imaging (MRI) scanning every 6 mo in the first year, then annually for the next five years, without reference to any role for trans-abdominal ultrasound (US). In this study, we report on our clinical experience of a follow-up strategy of image-based surveillance with US, and restricted use of MRI every two years and for urgent evaluation whenever suspicious changes are detected by US.


To report the results and cost-efficacy of a US-based surveillance follow-up for known PCNs, with restricted use of MRI.


We retrospectively evaluated the records of all the patients treated in our institution with non-surgical PCN who received follow-up abdominal US and restricted MRI from the time of diagnosis, between January 2012 and January 2017. After US diagnosis and MRI confirmation, all patients underwent US surveillance every 6 mo for the first year, and then annually. A MRI scan was routinely performed every 2 years, or at any stage for all suspicious US findings. In this communication, we reported the clinical results of this alternative follow-up, and the results of a comparative cost-analysis between our surveillance protocol (abdominal US and restricted MRI) and the same patient cohort that has been followed-up in strict accordance with the European guidelines recommended for an exclusive MRI-based surveillance protocol.


In the 5-year period, 200 patients entered the prescribed US-restricted MRI surveillance follow-up. Mean follow-up period was 25.1 ± 18.2 mo. Surgery was required in two patients (1%) because of the appearance of suspicious features at imaging (with complete concordance between the US scan and the on-demand MRI). During the follow-up, US revealed changes in PCN appearance in 28 patients (14%). These comprised main pancreatic duct dilatation (n = 1), increased size of the main cyst (n = 14) and increased number of PNC (n = 13). In all of these patients, MRI confirmed US findings, without adding more information. The bi-annual MRI identified evolution of the lesions not identified by US in only 11 patients with intraductal papillary mucinous neoplasms (5.5%), largely consisting of an increased number of very small PCN (P = 0.14). The overall mean cost of surveillance, based on a theoretical use of the European evidenced-based exclusive MRI surveillance in the same group of patients, would have been 1158.9 ± 798.6 € per patient, in contrast with a significantly lower cost of 366.4 ± 348.7 € (P < 0.0001) incurred by the US-restricted MRI surveillance used at our institution.


In patients with non-surgical PCN at the time of diagnosis, US surveillance could be a safe complementary approach to MRI, delaying and reducing the numbers of second level examinations and therefore reducing the costs.

Keywords: Ultrasound, Pancreatic cystic neoplasms, Magnetic resonance imaging, Surveillance

Core tip: Considering the high incidence of pancreatic cystic neoplasms (PCN) in the general population and the low risk of malignant progression in these patients, health care providers need to consider cost-effective follow-up programs. Current guidelines advise only magnetic resonance imaging (MRI) surveillance for the routine follow-up of these patients. This image-based surveillance carries issues concerning accessibility and high costs. The present retrospective analysis enrolling 200 patients has demonstrated that a modified surveillance based on ultrasound and restricted use of MRI is both safe and significantly more cost-effective. However, this retrospective study requires confirmation by a prospective randomized controlled clinical trial comparing the two follow-up regimens in patients with non-surgical PCN.