The Cyst Surveillance Program provides cutting edge services for patients with pancreatic cysts while conducting research to define best practices.
Several types of pancreatic cysts, or fluid-filled pockets, can develop on or within the pancreas. Relatively common, they are often detected incidentally during CT scans or MRI testing for other problems. Most pancreatic cysts will not become cancerous, but a small fraction of them will, and they may also cause abdominal pain or pancreatitis. For this reason, it is important to monitor pancreatic cysts with great care and to remove those that are at risk for becoming malignant.
It is not possible to determine from imaging alone which cysts are benign and which are malignant. This distinction requires more invasive testing such as endoscopic ultrasonography and fine-needle aspiration (EUS/FNA). Particularly when the cyst is not causing any symptoms, the onus is therefore on the diagnostician to identify which cysts have high-risk features and are likely to progress to cancer, and to make judgment calls about which patients should undergo more invasive testing or surgery, and which can be left to ongoing surveillance.
The Pancreas Center at NewYork-Presbyterian/Columbia University Medical Center established a dedicated cyst surveillance program in 2012 to provide comprehensive, long-term monitoring of patients with suspected or known pancreatic cysts. The program includes every multidisciplinary specialty needed to treat pancreatic cysts, such as dedicated radiologists, gastroenterologists and surgeons. The goal of this center is twofold: a) provide a comprehensive and systematic approach to surveillance of patients with pancreatic cysts, and b) enhance our understanding of how these cysts evolve over time by maintaining databases and conducting research based on this data.
Using new technologies to monitor patients, the clinic’s approach is highly methodical and more cautious than some others in the country. According to Tamas Gonda, MD, a therapeutic endoscopist and gastroenterologist with the program, a highly proactive approach makes sense based on data the center has been collecting and analyzing for the last decade. This data, which includes information about approximately 800 patients with pancreatic cysts, has provided crucial evidence that has shaped the center’s approach to care.
When to Treat? Benefit vs. Risk
In every area of medicine, doctors must weigh the benefits of a particular test or treatment against its costs, which may include not only dollars but also physical or emotional trauma to the patient, recovery time, and other factors. In the case of pancreatic cysts, experts at the pancreatitis clinic must consider whether the risk of cancer is sufficient to justify the cost, inconvenience, and possible effects of surveillance or treatment. The $64,000 question: when should cysts be monitored or treated, and when should they be left alone?
Nationally, experts have not yet reached consensus regarding how aggressively physicians should monitor and treat asymptomatic pancreatic cysts. Until recently, the standard guidelines included two sets of recommendations, one from the American College of Radiology and the other from the American Pancreas Association. In general, these call for indefinite surveillance of intraductal papillary mucinous neoplasm (IPMN) or any cyst that shows even one feature indicative of a high-risk lesion. In a move that was surprising to some experts, the American Gastroenterological Association (AGA) released yet another new, somewhat controversial set of guidelines in April, 2015. This edict calls for greater intervals of time between surveillance, and for clinicians to end surveillance at five years if a patient’s cyst does not demonstrate enough high-risk features (just one high risk feature is not enough to warrant continued surveillance in this system).
According to Dr. Gonda, the new AGA guidelines attempt to answer criticism that some centers are overly aggressive in treating and monitoring pancreatic cysts. The authors of the guidelines cite the need to balance the risks associated with treatment against uncertain benefits, because it remains unknown how frequently pancreatic cysts progress to cancer, making conclusive quantitative analysis of risk vs. benefit challenging.
In light of the center’s experience, the Pancreas Center will continue to offer the same thorough long-term surveillance and treatment, and will continue to monitor cysts with even one high-risk feature. As Dr. Gonda explains, the current sets of guidelines are useful in informing physicians, but are not definitive or conclusive. “We are doing our own research based on our data registry to understand how pancreatic disease evolves over time, to identify which patients are most likely to progress, and to identify who faces the highest risk for developing precancerous lesions. Through this process we hope to provide the least invasive but most accurate guidance to our patients, and minimize the anxiety associated with the possibility of developing pancreatic malignancy.”