EUS 2008 Working Group document: evaluation of EUS-guided pancreatic-cyst ablation

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Pancreatic cysts encompass a wide spectrum of morphologic and histopathologic types. 1 Broadly, they are classified into 2 main types, mucinous and nonmucinous, which differ natural history and clinical characteristics. The nonmucinous lesions include serous cystadenomas and cystic endocrine tumors. Mucinous cystic lesions may be benign, borderline, or malignant nature and include benign mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN). Mucinous cysts are unique their predisposition toward malignant transformation. The traditional therapy of cystic neoplasms, particularly mucinous lesions, has been surgical resection. There is now evidence to support clinical monitoring of low-risk mucinous lesions, such as side-branch IPMN lesions or those patients who are poor surgical candidates. Although small, incidental simple pancreatic cysts 2 cm or smaller may enlarge over a prolonged time. Morbidity or mortality because of these small simple cysts is extremely unlikely, and observation appears to be a safe management option. 2 Sahani et al 3 reported on 86 patients with cystic lesions less than 3 cm diameter that were resected after EUS-guided FNA. The majority (n = 75) of small pancreatic cysts were benign. Thirty-six cysts were unilocular, and virtually all of these (n = 35) were benign. The presence of septa was associated with borderline or in situ malignancy 20% of cases (10 of 50). Low-risk IPMNs the elderly are probably best managed with periodic imaging. 4 A report of a recent task force also recommended periodic imaging for cysts less than 3 cm diameter.5 A general schema for management of pancreatic-cyst neoplasm is shown Table 1. As an alternative to surgical resection or monitoring, EUS-guided ethanol ablation of pancreatic-cystic lesions may have a role carefully selected patients. This section of the EUS 2008 Working Group Proceedings will evaluate the current role of EUS-guided ethanol ablation the management of pancreatic cyst neoplasms and provide recommendations for future research this area.