From the Guidelines
The patient with a long-term stable uncinate process pancreatic cyst for 6 years can likely stop surveillance, as the risk of malignant transformation is very low, according to the American Gastroenterological Association (AGA) guideline 1. The AGA suggests against continued surveillance of pancreatic cysts if there has been no significant change in the characteristics of the cyst after 5 years, which is supported by the fact that the risk of malignant transformation of pancreatic cysts is approximately 0.24% per year 1. Some key points to consider in the management of this patient include:
- The stability of the cyst over 6 years is a strong indicator of its benign nature
- The uncinate process location, while important for potential future intervention, does not change the current management approach
- Patients should be advised to report any new symptoms, but in the absence of these, continued observation is not necessary
- The AGA guideline provides a conditional recommendation, but the very low quality evidence and the small risk of malignant progression in stable cysts support stopping surveillance 1. Given the low risk of malignant transformation and the costs and risks associated with continued surveillance, stopping surveillance for this patient is a reasonable approach, as supported by the AGA guideline 1.
From the Research
Long Term Interval Stability of an Uncinate Process Pancreatic Cyst
- The stability of an uncinate process pancreatic cyst over a long term interval, such as 6 years, can be evaluated using various diagnostic techniques, including endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) 2.
- A study published in 2021 found that FNA using a flexible needle can be particularly valuable in sampling cystic lesions in the pancreatic head/uncinate process, with a high success rate and low adverse event rate 2.
- The management of incidentally detected pancreatic cystic lesions, including those in the uncinate process, depends on the type of lesion and its potential for malignancy, with benign lesions often being left alone and lesions with high malignant potential undergoing resection 3, 4.
- A novel surgical technique involving removal of the uncinate process of the pancreas combined with medial pancreatectomy has been developed for the management of multiple mucin-producing tumors of the pancreas localized in the uncinate process and body of the pancreas, with preservation of normal pancreatic tissue and maintenance of pancreatic juice flow into the duodenum 5.
Diagnostic Techniques
- Endoscopic techniques, such as EUS and EUS-guided FNA, are increasingly being used for the diagnosis of pancreatic cystic lesions, with varying diagnostic and adverse event rates reported in clinical studies 6.
- Cross-sectional imaging, such as CT and MRI, can be used to follow up benign-appearing lesions and stage more aggressive ones, with the addition of EUS/FNA and cyst fluid analysis increasing the diagnostic yield in appropriately selected patients 3, 4.
Management
- The management of pancreatic cystic lesions, including those in the uncinate process, requires a systematic approach, with initial investigation using specific pancreas protocol CT or contrast-enhanced MRI with MRCP, and surgical intervention indicated in otherwise fit patients with mucinous neoplasms 4.