European evidence-based guidelines on pancreatic cystic neoplasms (2018)
Europe's guideline for pancreatic cysts, covering every cyst type and not only IPMN. It splits reasons to operate into absolute and relative indications and recommends lifelong surveillance for IPMN in anyone fit for surgery.
Overview
Guideline from the European Study Group on Cystic Tumours of the Pancreas, produced with a formal evidence review and covering IPMN, mucinous cystic neoplasm, serous cystic neoplasm, solid pseudopapillary neoplasm and cystic neuroendocrine tumours. Absolute indications for surgery in IPMN are positive cytology for malignancy or high-grade dysplasia, a solid mass, jaundice, an enhancing mural nodule of 5 mm or more and a main duct of 10 mm or more. Relative indications include growth of 5 mm or more per year, raised CA19-9, a main duct of 5 to 9.9 mm, cyst diameter of 40 mm or more, new-onset diabetes, acute pancreatitis and a mural nodule under 5 mm.
IPMN surveillance is lifelong while the patient remains fit for surgery; serous cystadenomas need no follow-up once diagnosed; mucinous cystic neoplasms of 40 mm or more or with symptoms or risk features are resected.
- Absolute surgical indications: positive cytology, solid mass, jaundice, enhancing nodule 5 mm or more, main duct 10 mm or more.
- Relative indications: growth 5 mm per year, raised CA19-9, main duct 5 to 9.9 mm, cyst 40 mm or more, new diabetes, pancreatitis, nodule under 5 mm.
- Lifelong IPMN surveillance while fit for surgery; no follow-up for serous cystadenoma.
European centres manage pancreatic cysts by this guideline; its lifelong surveillance stance is the main point of difference from the American and Kyoto guidelines.
- Evidence for most recommendations is low quality and consensus-based.
- Lifelong surveillance has a cost and burden that has not been tested against stopping rules in trials.
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