Mayo-Smith
While pancreatic cysts are a common finding, they are often small and present minimal risk to patients. But since some cysts can grow and become malignant, there is ongoing debate among radiologists about how aggressively to treat these cysts, how long to surveil patients and which guidelines to follow.
During a Wednesday Controversy Session, "Incidental Pancreatic Cyst Management," experts discussed the issue, presented differing opinions on the American College of Radiology (ACR) management guidelines and discussed challenges created by competing guidelines and recommendations.
Unnecessary Imaging?
Moderator William Mayo-Smith, MD, vice-chair and professor of radiology at Brigham & Women's Hospital, Harvard Medical School, Boston, said the incidental pancreatic cyst is a "nightmare" scenario for him.
"This is a common problem, but I'm not sure we are really helping the patients," Dr. Mayo-Smith said. "We have 'invented' the disease of pancreatic cysts in the last 40 years with higher resolution abdominal imaging detecting things we never saw before."
Dr Mayo-Smith said these cysts and prolonged follow-up surveillance contributes to what he considers to be a high volume of unnecessary imaging in the United States.
CT volume hit an all-time high in 2019 — much higher than in other developed countries, he said. Too much imaging can lead to a cascade of testing for patients that increases emotional stress, health care costs and radiation dose.
Ivan Pedrosa, MD, PhD, vice-chair of radiology research at the University of Texas Southwestern, Dallas, cited research showing that incidental pancreatic cysts were found in 24% of autopsies.
These cysts were found in 13.5% of MRIs for non-pancreatic disease. In patients over the age of 70, that number was as high as 40% to 50%, according to research cited by Dr. Pedrosa.
He also cited research showing that 94% of all cysts were less than 10 mm in size and malignant cancers were very rare.
Conflicting Guidelines Create Confusion
Several presenters said that conflicting sets of guidelines about how to handle incidental pancreatic cysts are complicating the issue and making physician decisions more difficult.
The ACR published its guidelines in 2017, updating earlier recommendations from 2010. But there are other guidelines established by the American Gastroenterology Society, the American College of Gastroenterology as well as European evidence-based guidelines. Each recommends slightly different populations for increased surveillance, different sizes at which cysts should be considered worrisome or high risk, and different standards for when to stop surveillance.
"It's not surprising that when different gastroenterologists in academia and private practice are asked what is the optimal size threshold to refer a patient for endoscopic ultrasound or how long should we continue surveillance in these patients, we get completely different answers," Dr. Pedrosa said.
Debating the ACR Guidelines
Elizabeth M. Hecht, MD, vice-chair of Academic Affairs and Faculty Development in the Department of Radiology at Weill Cornell Medicine, New York City, argued that radiologists should follow the 2017 ACR management recommendations, which take an algorithmic approach by first looking at cyst size, followed by patient age and other risk factors to make a decision.
"While most incidental cysts are clinically insignificant, there is a chance the lesions develop into cancers or cancer develops elsewhere in the gland," Dr. Hecht said. "It's a delicate balance we are trying to achieve between who needs surveillance and who needs further intervention."
Dr. Hecht argued that there are benefits to standardizing care and that if more radiologists followed the ACR guidelines, it could improve communication, data collection and patient outcomes.
She referenced a 2018 survey in which 42% of radiologists said they were already following the ACR guidelines. The guidelines could also be cost effective, add value and offer a way to follow up on low-risk lesions that helps patients, she said.
However, David Hough, MD, abdominal radiologist at the Mayo Clinic, Rochester, MN, argued against the ACR guidelines, citing the slow growth and low risk for incidental pancreatic cysts.
He referenced a 2019 study that found that 100% of cysts under 5 mm showed no growth at three years.
"So, does it really make sense to be imaging people so frequently? Do we really want to be following this many patients?" Dr. Hough asked.
Dr. Hough said measures such as the Dutch-American Risk Stratification Tool, which assesses other factors including smoking history and history of pancreatitis along with size of the cyst, can identify which patients should be followed more closely.
For More Information
View the RSNA 2020 session Incidental Pancreatic Cyst Management — SPSC44 at RSNA2020.RSNA.org.
