What are the findings and management of pancreatic mucinous cystadenoma?

From the Guidelines

Surgical resection is the primary management approach for pancreatic mucinous cystadenomas, with the goal of preventing malignant transformation and improving patient outcomes. The management of pancreatic mucinous cystadenomas (MCNs) involves a multidisciplinary approach, considering the patient's overall health status, the location and size of the lesion, and the risk of malignant transformation.

Key Considerations

• The European evidence-based guidelines on pancreatic cystic neoplasms recommend a standard oncologic resection, such as distal pancreatectomy, with lymph node dissection and splenectomy, for MCNs with imaging features indicating high-grade dysplasia or cancer 1.
• For MCNs without suspect features and a low risk of malignancy, a non-oncological resection, such as distal pancreatectomy with splenic preservation, may be considered 1.
• The American Gastroenterological Association (AGA) guidelines suggest that patients with pancreatic cysts <3 cm without a solid component or a dilated pancreatic duct undergo MRI for surveillance in 1 year and then every 2 years for a total of 5 years if there is no change in size or characteristics 1.

Surgical Approach

• The surgical approach depends on the location and size of the lesion, with distal pancreatectomy being the most common procedure for body/tail lesions and pancreaticoduodenectomy (Whipple procedure) for head lesions.
• The decision for surgery should consider the patient's overall health status, as these procedures carry significant morbidity risks, including pancreatic fistula, infection, and bleeding.

Postoperative Follow-up

• Postoperative follow-up includes regular imaging surveillance to detect recurrence, though this is uncommon after complete resection.
• Patients generally have an excellent prognosis following complete surgical removal, with 5-year survival rates exceeding 95% 1.

From the Research

Findings of Pancreatic Mucinous Cystadenoma

• Pancreatic mucinous cystic neoplasms (MCN) occur almost exclusively in women (female:male 20:1) and are mainly located in the pancreatic body or tail (93-95%) 2.
• MCNs are usually found incidentally at the age of 40-60 years 2.
• The criterion for surgical resection of MCNs remains uncertain and differs between guidelines 2.
• In resected MCNs, 0-34% are malignant, but in those less than 4 cm only 0.03% were associated with invasive adenocarcinoma 2.

Management of Pancreatic Mucinous Cystadenoma

• Surgical resection is the primary treatment modality for mucinous cystadenocarcinoma (MCC) and mucinous cystadenoma (MCA) 3.
• The management of MCNs is defined by the consensus European, International Association of Pancreatology and American College of Gastroenterology guidelines 2.
• A selective therapeutic approach toward pancreatic cystic neoplasms is recommended, with observation for typically benign lesions and upfront resection for likely malignant lesions 4.
• Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound (EUS) or surgical resection 5, 6.
• Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy, as suggested by various risk features including solid mass, nodule, and dilated main pancreatic duct 5, 6.

Diagnostic Tools

• Cross-sectional imaging and endoscopic ultrasound are the most frequently used diagnostic tools for MCNs, but often it is impossible to differentiate MCNs from branch duct intraductal papillary mucinous neoplasms (BD-IPMN) or oligocystic serous adenomas pre-operatively 2.
• EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging 5.
• Various cyst fluid markers including carcinoembryonic antigen, glucose, amylase, cytology, and DNA markers help distinguish mucinous from nonmucinous cysts 5.

Prognosis

• Five-year survival after surgical resection of a malignant MCN is approximately 60% 2.
• No surgically resected benign MCNs were associated with a synchronous lesion or recurrence; therefore further follow-up is not required after resection 2.
• Tumor size, age, and serum CEA, CA19-9, and CA12-5 levels may contribute to management of patients with MCN 3.