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

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 in natural history and clinical characteristics. The nonmucinous lesions include serous cystaclenomas and cystic endocrine tumors. Mucinous\ Cystic lesions may be benign, borderline, or malignant in nature and include benign mucinolis cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN). Mucinous cysts are unique in 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 in 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) reporated on 86 patients with cystic lesions sions less that' 3 c1l, in 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 in 20% of cases (10 of 50). Low-risk IPMNs in the elderly are probably best managed with periodic imaging. A report of a recent task force also recommended periodic imaging for cysts less than 3 cm in diameter 5 A general schema for management of pancreatic-cyst neoplasm is shown in Table 1. As an alternative to surgical resection or monitoring, EUS-guided ethanol ablation of pancreatic-cystic lesions may have a role in carefully selected patients. This section of the EUS 2008 Working Group Proceedings will evaluate the current role of EUS-guided ethanol ablation in the management of pancreatic cyst neoplasms and provide recommendations for future research in this area.