Published online May 14, 2019. doi: 10.3748/wjg.v25.i18.2217
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.
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.