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World J Gastrointest Endosc. Mar 16, 2015; 7(3): 213-223
Published online Mar 16, 2015. doi: 10.4253/wjge.v7.i3.213
Endosonography in the diagnosis and management of pancreatic cysts
Vivek Kadiyala, Linda S Lee
Vivek Kadiyala, Linda S Lee, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA 02115, United States
Linda S Lee, Harvard Medical School, Boston, MA 02115, United States
Author contributions: Kadiyala V and Lee LS solely contributed to this paper.
Conflict-of-interest: The authors declare that they have no competing interests.
Open-Access: This article is an open-access article which 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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Linda S Lee, MD, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, United States. lslee@partners.org
Telephone: +1-617-2780359 Fax: +1-617-2645132
Received: August 29, 2014
Peer-review started: August 30, 2014
First decision: September 19, 2014
Revised: September 30, 2014
Accepted: December 16, 2014
Article in press: December 17, 2014
Published online: March 16, 2015
Abstract

Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no risk of malignancy, neoplastic non-mucinous serous cystadenomas with little or no risk of malignancy, as well as neoplastic mucinous cysts and solid pseudopapillary neoplasms both with varying risk of malignancy. Accurate diagnosis is imperative as management is guided by symptoms and risk of malignancy. Endoscopic ultrasound (EUS) allows high resolution evaluation of cyst morphology and precise guidance for fine needle aspiration (FNA) of cyst fluid for cytological, chemical and molecular analysis. Initially, clinical evaluation and radiologic imaging, preferably with magnetic resonance imaging of the pancreas and magnetic resonance cholangiopancreatography, are performed. In asymptomatic patients where diagnosis is unclear and malignant risk is indeterminate, EUS-FNA should be used to confirm the presence or absence of high-risk features, differentiate mucinous from non-mucinous lesions, and diagnose malignancy. After analyzing the cyst fluid for viscosity, cyst fluid carcinoembryonic antigen, amylase, and cyst wall cytology should be obtained. DNA analysis may add useful information in diagnosing mucinous cysts when the previous studies are indeterminate. New molecular biomarkers are being investigated to improve diagnostic capabilities and management decisions in these challenging cystic lesions. Current guidelines recommend surgical pancreatic resection as the standard of care for symptomatic cysts and those with high-risk features associated with malignancy. EUS-guided cyst ablation is a promising minimally invasive, relatively low-risk alternative to both surgery and surveillance.

Keywords: Endoscopic ultrasound, Pancreatic cyst, Serous cystadenoma, Intraductal papillary mucinous neoplasms, Mucinous cystic neoplasm, Solid pseudopapillary neoplasms, diagnosis, Management, Ablation

Core tip: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is an important and safe diagnostic tool in pancreatic cystic lesions to help diagnose malignancy, identify features concerning for malignancy, and differentiate mucinous from non-mucinous cysts. More recently EUS-guided pancreatic cyst ablation may offer a minimally invasive and safer alternative to surgical resection for carefully selected pancreatic cysts.