Are any of the following high-risk stigmata of malignancy present?
i. Obstructive jaundice in a patient with cystic lesion of the head of the pancreas
ii. Enhancing solid component within cyst
iii. Main pancreatic duct ≥ 10 mm in size
Are any of the following worrisome features present?
Imaging: i. Cyst ≥ 3 mm,
ii. Thickened/enhancing cyst walls,
iii. Main duct size 5-9 mm,
iv. Non-enhancing mural nodule,
v. Abrupt change in caliber of pancreatic duct with distal pancreatic atrophy
If yes, perform
Are any of thse features present?
i. Defnite mural nodule(s)b
ii. Main duct features suspicious for involvementc
iii. Cytology: suspicious or positive for malignancy
What is the size of the largest cyst?
Consider surgery if
< 1 cm 1-2 cm 2-3 cm > 3 cm
CT/MRI yearly x 2 years, then
lengthen interval if no changed
EUS in 3-6 months, then lengthen interval
alternating MRI with EUS as appropriate.d
Consider surgery in young, ft patients with need
for prolonged surveillance
Close surveillance alternating
MRI with EUS every 3-6 months.
Strongly consider surgery in
young, ft patients
a. Pancreatitis may be an indication for surgery for relief of symptoms.
b. Differential diagnosis includes mucin. Mucin can move with changes in patient poistion, may be dislodged on cyst lavage, and does not have Doppler fow.
Features of true tumor nodule include lack of mobility, presence of Doppler fow, and FNA of nodule showing tumor tissue.
c. Presence of any one of thickened walls, intraductal mucin, or mural nodules is suggestive of main duct involvement.
In their absence main duct involvement is inconclusive.
d. Studies from Japan suggest that on follow-up of subjects with suspended BD-IPMN there is increased incidence of pancreatic ductal adenocarcinoma unrelated
to malignant transformation of the BD-IPMN(s) being followed. However, it is unclear if imaging surveillance can detect early ductal adenocarcinoma and, if so,
at what interval surveillance imaging should be performed.