Pancreatic Cysts

By Bechien Wu, MD

Brigham and Women’s Hospital

I have a cyst in my pancreas…now what?

With increasing use of imaging tests such as computed tomography (CT) or magnetic resonance imaging (MRI), pancreatic cysts are now being detected with increasing frequency.  If you or someone you care about has been recently diagnosed with a cyst of the pancreas, you are not alone.  The intent of this post is to provide some basic information related to cysts of the pancreas as well as a provide brief guide on how to go about developing a management plan that is best suited to your needs.

It’s important that we acknowledge the anxiety that comes hand-in-hand with being told of a cyst in the pancreas.  In many cases, these cysts are detected on a CT or MRI scan obtained for an entirely different reason.  After being informed of this new finding, you may have already searched the internet to learn more about the nature of these cysts.  Unfortunately, much of the scientific literature is filled with a dizzying array of terms like serous cystadenoma, intraductal papillary mucinous neoplasia or mucinous cystic neoplasm.  The sheer complexity of the nomenclature can be discouraging when trying to figure out 1) Do I have cancer? and 2) If not, what are the chances that this cyst may some day develop into a cancer?

Where to begin?

Because of the wide variety of cysts than can arise in the pancreas, it’s a good idea to schedule a visit with someone that has experience in managing these lesions.  Several centers around the country including ours now offer comprehensive consultation services for the evaluation of pancreatic cysts.  There are several additional steps you can take to be as informed as possible: 1) keep a copy of both the original report and actual digital images from your imaging test: you are entitled to copies of these as part of your medical record.  The actual images on a compact disc or other digital media will enable you to quickly obtain a second opinion if necessary.  2) Be proactive.  Ask your local provider what type of cyst they think you have and why.  Are there additional tests that they recommend?  Do they think a second opinion would be worthwhile? 3) Know your history.  Have you ever had acute pancreatitis?  This is important information for your physician to know, as fluid collections that arise as a result of acute pancreatitis are very different from other types of cysts in the pancreas.

A bit of background

In general, there are two main varieties of pancreatic cysts based on the type of fluid they contain.  The most common cysts are either serous (containing a thin type of fluid) or mucinous (containing a thicker, more viscous fluid).  For the most part, serous cysts tend to be benign (non-cancerous).  Most of the mucinous cysts are benign as well although there are a few subtypes that can be more concerning.  These include the mucinous cystic neoplasm (MCN) that contain ovarian tissue and are almost exclusively found in women as well as main-duct intrapapillary mucinous neoplasm (IPMN), a type of mucinous cyst that contains many tiny fingerlike projections that involves the main pancreatic duct.

What’s next?

In many cases, your doctor may be able to get a sense of what type of cyst you have based on the already available imaging tests.  Otherwise, MRI can be especially useful for further characterization.  If potentially concerning features are detected on imaging studies or if there remains significant uncertainty related to the nature of the cyst, additional information can be gained by an endoscopic ultrasound.  This test is similar to a regular ultrasound (as in pregnancy) except that we use a probe connected to an endoscope.   Once the endoscope is passed into the stomach, we can obtain up-close images of the pancreas.  If you have never had upper endoscopy, the procedure is relatively brief and uses sedation similar to that used for colonoscopy.  Using endoscopic ultrasound, we can also obtain a sample of the fluid from the cyst, which can provide further diagnostic information.

What treatment is available?

At present, the only curative treatment is surgery.  As any surgery on the pancreas is a major undertaking.  Therefore, it is best to reserve resection for cases in which there is a significant concern for cancer.  This represents a minority of cases.  In the vast majority of cases, surveillance with periodic imaging tests is all that is needed.

What approach is going to be best for me?

You should be aware that the management of these cysts continues to evolve.  Researchers in the field are working diligently to identify more accurate early markers of malignancy.  Further research is being conducted to determine the best surveillance interval to monitor these cysts.  In the meantime, it is important that you work together with your healthcare provider to arrive at the best management plan to suit your individual needs.