Pancreatic Cysts: Much Ado or Not Enough?

Evidence rightly has become the holy grail for the practice of medicine. However, quality evidence for diseases that are uncommon remains elusive. Clinical management of these uncommon diseases often is based on expert opinion, which may favor intervention rather than observation. Pancreatic cystic lesions are perfect examples of this diagnostic dilemma. Advances in radiologic technology combined with a more frequent use of abdominal imaging are contributing to the increasing identification of asymptomatic pancreatic cysts. Patients with incidentally discovered pancreatic cysts generally see gastroenterologists in consultation. The gastroenterologist then has the difficult job of explaining to a patient who is symptom free that he or she has a condition that may be completely benign with no potential for malignancy, may be benign but could become malignant, or already may be malignant. Furthermore, the patient needs to be informed that the management options are as follows: to do nothing, to observe the cyst with noninvasive imaging tests that may or may not detect malignancy before it is too late to treat effectively, to perform invasive imaging tests such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) that may or may not be diagnostic, or to go directly to surgical resection. Depending on the location of the cyst and the skill of the surgeon, surgery may be associated with a mortality rate of up to 10%. After such a consultation the gastroenterologist and the patient both are left feeling uneasy. When it comes to pancreatic cysts discovered incidentally on computed tomography imaging, are we making much ado about nothing or not doing nearly enough?