Increasing incidental detection of pancreatic cysts means there is an urgent need to improve risk stratification in order to reduce operations on benign disease, delegates have heard.
Speaking during the “Presidents’ Plenary Picks” session Andrew Metz from Cambridge University in the UK said that while endoscopy had made a previously inaccessible organ accessible, it had presented us with “a large unrecognised volume of disease that we’re still not quite sure what to do with”.
For instance increased investigations meant pancreatic cysts were now found in up to 2% of CT scans and 13% of MRIs. With increasing resolution this figure could potentially grow to 25%, he told delegates.
While cysts possessed malignant potential, some had an indolent natural history with a 10-year risk to invasive cancer of 30%.
However differentiating between the non muscinous cyst (pseudocyst) compared with the muscinous intraductal papilliary mucinous neoplasms (IPMNs) that do have a cancer risk was rarely achieved pre-operatively, he explained.
CEA cytology was the mainstay of investigation but was “poorly accurate,” leaving surgical resection as the only current intervention.
Yet surgery was associated with mortality and morbidity and should not be taken lightly given that many patients presented in their sixth or seventh decade.
“We’re operating a lot on benign disease — up to 33% — and our own figures over the past 6 years have shown that over half of patients operated on had a low risk IPMN that might never have changed into malignancy over time,” he said.
Even more concerning was that half of those who had undergone investigation and resection had pseudocysts with absolutely no malignant potential.
Another issue was that guidelines now recommended following potentially for life patients with cysts that cannot be definitively proven to be benign.
“We’re left with an incredibly common condition with an incredibly high operative rate on benign lesions and the risk of an unmanageable surveillance cohort that could overwhelm radiology and endoscopic departments around the world”.
The situation showed there was an urgent need for improved risk stratification or minimally invasive treatment in pancreatic cysts, Metz told delegates.
“All of these patients should be managed in an MDT situation to absolutely standardise care and patient outcomes,” he added.
Dr Metz has been based at Cambridge University for the past six years but is due to return to Australia at next month to take up a position as head of endoscopy at the Royal Melbourne Hospital.