In a 57‑year‑old woman with a family history of pancreatic cancer who has two pancreatic cystic lesions measuring 6 × 3 mm and 3 × 2 mm on MRI, what is the recommended management?

Management of Small Pancreatic Cysts in a Patient with Family History of Pancreatic Cancer

This patient requires formal pancreatic cancer surveillance with annual alternating MRI/MRCP and EUS, with the current small cysts (<1 cm) followed at 12-month intervals without immediate intervention. 1

Risk Assessment and Surveillance Eligibility

This 57-year-old woman does not automatically qualify for high-risk pancreatic cancer surveillance based solely on having "a relative" with pancreatic cancer. 1 The International Cancer of the Pancreas Screening (CAPS) Consortium requires specific criteria:

• At least 2 affected first-degree relatives (FDRs) who are FDRs to each other, with at least one being an FDR to the patient (88% consensus) 1
• At least 3 affected blood relatives on the same side of the family, with at least one being an FDR (97% consensus) 1
• Known germline mutations (BRCA2, PALB2, ATM, MLH1/MSH2) require at least one affected FDR 1, 2

Critical caveat: If this patient's family history meets the above criteria (which requires clarification of the exact relationship and number of affected relatives), she should be enrolled in formal surveillance. If not, these cysts should be managed as sporadic incidental findings. 1

Management of the Current Pancreatic Cysts

Immediate Assessment

These cysts (6×3 mm and 3×2 mm) are very small and lack worrisome features based on size alone. 1

Worrisome features that would alter management include: 1

• Cyst ≥3 cm
• Thickened/enhancing cyst wall
• Main pancreatic duct (MPD) 5-9 mm
• Non-enhancing mural nodule
• Abrupt change in MPD caliber with distal pancreatic atrophy

High-risk stigmata requiring immediate surgical evaluation include: 1

• Obstructive jaundice in a patient with cystic lesion of the head
• Enhancing solid component or mural nodule
• MPD ≥10 mm

Surveillance Protocol

For cysts without worrisome features (as in this case): 1

• Repeat imaging in 12 months (83.7% consensus) 1
• Use alternating MRI/MRCP and EUS for ongoing surveillance 1
• Annual surveillance is appropriate for patients with non-concerning pancreatic abnormalities 1

Baseline surveillance should include: 1

• MRI/MRCP + EUS (92% and 87% agreement respectively) 1
• Fasting serum glucose and/or HbA1c (76% agreement) 1
• CA 19-9 only if concerning abnormalities develop 1

If Patient Qualifies as High-Risk Individual

Starting age for surveillance: 1

• For familial pancreatic cancer kindred (without known mutation): Start at age 50 or 55, or 10 years younger than youngest affected blood relative 1
• This 57-year-old patient is already at appropriate screening age 1

Surveillance imaging modality: 1

• Alternate MRI/MRCP and EUS (no firm consensus on exact alternating schedule, but annual surveillance is standard) 1
• EUS detects pancreatic lesions better than CT (42.6% vs 11% detection rate) 3
• MRI detects lesions better than CT (33.3% vs 11%) 3

When to Escalate Management

EUS with fine-needle aspiration (FNA) is indicated for: 1

• Solid lesions ≥5 mm 1, 2
• Cystic lesions with worrisome features 1
• Asymptomatic MPD strictures (with or without mass) 1

Repeat imaging in 3-6 months if: 1

• Concerning abnormalities develop that don't warrant immediate surgery 1
• New MPD dilation or stricture without mass 1
• Cyst develops worrisome features 1

Surgical resection is indicated for: 1

• Solid lesions >5 mm without definitive benign diagnosis after additional evaluation 1, 2
• Cysts with high-risk stigmata 1
• Positive FNA cytology 1

Critical Implementation Points

All surveillance and surgical management must occur at high-volume specialty centers with multidisciplinary teams experienced in hereditary pancreatic cancer. 2 This is essential because:

• Small (<1 cm) solid lesions detected only by EUS can be difficult to manage and may represent benign lesions (neuroendocrine tumors or low-grade PanIN) 1
• Risk of overtreatment is significant given 1-2% surgical mortality 1
• Decision-making requires expert multidisciplinary review considering mutation status, family history, operative risk, and life expectancy 1

Common pitfall: Do not perform ERCP for evaluation of small cystic lesions (77.5% disagreement in guidelines) due to 7% pancreatitis rate without improved diagnostic yield. 1