Pancreatic cyst surveillance imposes low psychological burden

Diagnosis and Management of Pancreatic Cysts

As pancreatic cyst incidence rises, likely due to the ubiquitous increase in cross-sectional imaging, their management presents multiple challenges for both the practitioner and patient. It is critical that all pancreatic cysts are appropriately characterized, as treatment decisions depend on an accurate diagnosis. Diagnostic modalities such as cytology, biopsy, and cyst fluid biomarkers allow for definitive diagnosis of virtually all lesions. Some cysts, such as intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, and cystic pancreatic endocrine neoplasms, have malignant potential and must be surveyed. Other cysts, such as serous cystadenomas and pancreatic fluid collections, do not have malignant potential. Surveillance strategies vary widely depending on cyst type and size and while multiple medical societies advocate surveillance, their published surveillance guidelines are heterogenous. Cysts with high-risk stigmata or worrisome features are usually resected, depending on the patient's surgical fitness. In patients unfit for resection, newer endoscopic ablative techniques are advocated. Controversial aspects regarding cyst management include whether surveillance can be stopped, how surveillance should be performed, and the extensive financial burden cyst management places on the health care system. Further study into the natural history of cystic lesions, including definitive determination of the rate of malignant transformation for each cyst type, is essential.

Exploring patient experiences of surveillance for pancreatic cystic neoplasms: a qualitative study

BACKGROUND

Pancreatic cystic neoplasms (PCN) are considered premalignant conditions to pancreatic adenocarcinoma with varying degrees of cancerous potential. Management for individuals who do not require surgical treatment involves surveillance to assess for cancerous progression. Little is known about patients' experience and the impact of living with surveillance for these lesions.

AIMS

To explore the experiences of patients living with surveillance for PCNs.

METHODS

Semi-structured qualitative interviews were conducted with patients under surveillance for pancreatic cystic neoplasms in the UK. Age, gender, time from surveillance and surveillance method were used to purposively sample the patient group. Data were analysed using reflexive thematic analysis.

RESULTS

A PCN diagnosis is incidental and unexpected and for some, the beginning of a disruptive experience. How patients make sense of their PCN diagnosis is influenced by their existing understanding of pancreatic cancer, explanations from clinicians and the presence of coexisting health concerns. A lack of understanding of the diagnosis and its meaning for their future led to an overarching theme of uncertainty for the PCN population. Surveillance for PCN could be seen as a reminder of fears of PCN and cancer, or as an opportunity for reassurance.

CONCLUSIONS

Currently, individuals living with surveillance for PCNs experience uncertainty with a lack of support in making sense of a prognostically uncertain diagnosis with no immediate treatment. More research is needed to identify the needs of this population to make improvements to patient care and reduce negative experiences.

Surveillance of Pancreatic Cystic Neoplasms

Pancreatic cystic neoplasms (PCNs) are increasingly detected because of the widespread use of cross-sectional imaging and overall aging population. While the majority of these cysts are benign, some can progress to advanced neoplasia (defined as high-grade dysplasia and invasive cancer). As the only widely accepted treatment for PCNs with advanced neoplasia is surgical resection, accurate preoperative diagnosis, and stratification of malignant potential for deciding about surgery, surveillance or doing nothing remains a clinical challenge. Surveillance strategies for pancreatic cysts (PCNs) combine clinical evaluation and imaging to assess changes in cyst morphology and symptoms that may indicate advanced neoplasia. PCN surveillance heavily relies on various consensus clinical guidelines that focus on high-risk morphology, surgical indications, and surveillance intervals and modalities. This review will focus on current concepts in the surveillance of newly diagnosed PCNs, especially on low-risk presumed intraductal papillary mucinous neoplasms (those without worrisome features and high-risk stigmata), and appraise current clinical surveillance guidelines.

Burden of New Pancreatic Cyst Diagnosis

Pancreatic cysts are an increasingly identified entity with significant health care implications. Although some cysts present with concurrent symptoms that often require operative intervention, the advent of improved cross-sectional imaging has heralded an era of increased incidentally detected pancreatic cysts. Although the rate of malignant progression in pancreatic cysts remains low, the poor prognosis of pancreatic malignancy has driven recommendations for ongoing surveillance. A uniform consensus has not been reached on the management and surveillance of pancreatic cysts leading clinicians to grapple with the burden of how best to approach pancreatic cysts from a health, psychosocial, and cost perspective.

When to Stop Surveillance: Pancreatic Cysts

Surveillance of mucinous pancreatic cysts is a key to reducing pancreatic cancer risk and detecting malignancy early. However, while the management of cysts with high-risk and worrisome features is fairly straightforward, surveillance of patients with low-risk branch-duct intraductal papillary mucinous neoplasms has long presented gastroenterologists with the challenging question of discontinuation of surveillance. Up-to-date evidence supports the cessation of follow-up in these patients depending on both interval stability of the cyst and cyst size. Based on these criteria, discontinuation of surveillance at either 5 years or 10 years is recommended. Oversurveillance of patients with pancreatic cysts in the absence of high-risk and worrisome features is discouraged.

Health-related quality of life and anxiety levels among patients under surveillance for intraductal papillary mucinous neoplasm

BACKGROUND

Because of the premalignant nature of intraductal papillary mucinous neoplasms (IPMNs), patients should undergo surveillance as long as they remain fit for surgery. This surveillance, with imaging and laboratory tests every 6 to 12 months, is expensive and may psychologically burden patients. This study aimed to determine the effects of IPMN surveillance on patients´ health-related quality of life (HRQoL) and anxiety levels.

METHODS

We included a random subgroup of all IPMN patients undergoing a follow-up check-up at Helsinki University Hospital (HUH) between August 2017 and November 2018. Patients were asked to complete the 15D HRQoL and state-trait anxiety inventory (STAI) questionnaires just before and three months after an IPMN control.

RESULTS

Among 899 patients in IPMN follow-up, 232 participated. The 15D HRQoL results showed differences in some IPMN patients' 15 analyzed dimensions compared to a sex- and age-standardized general population cohort, but the clinical relevance of these differences appear doubtful. We detected no significant difference in the anxiety levels determined using the STAI questionnaires before or three months after the IPMN control.

CONCLUSION

Surveillance should be less harmful than the risk of disease. Among our patients, the recommended IPMN follow-up carried minimal negative impact on patients' HRQoL or anxiety levels. This result is important, because the number of patients under IPMN surveillance is rapidly increasing and the cancer risk among the majority of these patients remains small.

TRIAL REGISTRATION

The Surgical Ethics Committee of Helsinki University Hospital approved this study (Dnro HUS 475/2017) and it was registered at ClinicalTrials.gov (NCT03131076) before patient enrollment began.

Pancreatic Cystic Lesions: Review of the Current State of Diagnosis and Surveillance

Pancreatic cystic lesions (PCLs) are both common and often incidental. These encompass a range of pathologies with varying degrees of concern for malignancy. Although establishing a diagnosis is helpful for determining malignant potential, many PCLs are either too small to characterize or demonstrate nonspecific morphologic features. The most salient modalities involved in diagnosis and surveillance are magnetic resonance imaging, multidetector computerized tomography, and endoscopic ultrasound. Fine needle aspiration has a role in conjunction with molecular markers as a diagnostic tool, particularly for identifying malignant lesions. Although several major consensus guidelines exist internationally, there remains uncertainty in establishing the strength of the association between all PCLs and pancreatic adenocarcinoma, and in showing a benefit from extended periods of imaging surveillance. No consensus exists between the major guidelines, particularly regarding surveillance duration, frequency, or endpoints. This review paper discusses PCL subtypes, diagnosis, and compares the major consensus guidelines with considerations for local adaptability along with questions regarding current and future priorities for research.

Robotisch gestützte Enukleation einer zystischen Neoplasie des Pankreaskopfes

Laut aktuellen revidierten Fukuoka-Leitlinien besteht die Indikation zur Resektion von BD-IPMN des Pankreas mit Worrisome Features, da hier ein Risiko der malignen Entartung von bis zu 30% besteht. Die Resektion kann bei fehlenden klinischen, bildmorphologischen und laborchemischen Malignitätszeichen als eine nicht anatomische, lokale Exzision durchgeführt werden.

Eine robotische Enukleation bei benignen Raumforderungen der Bauchspeicheldrüse stellt eine sehr gute Alternative zu den resezierenden Verfahren, insbesondere zu denjenigen in offener Technik, dar. Diese operative Behandlungsoption wird bei einem Mindestabstand bis zum pankreatischen Hauptgang von mindestens 2 mm im „International consensus statement on robotic pancreatic surgery“ nahegelegt.

Neben den bekannten Vorteilen der minimalinvasiven Chirurgie führt diese parenchymsparende Methode zum Erhalt von endo- und exokriner Funktion (ca. 90%) und zu einem progressfreien 10-Jahres-Überleben von ca. 75% bei etwas erhöhter Morbidität (ca. 60%) verglichen mit den resezierenden Verfahren.

Der folgende Videobeitrag präsentiert das Operationsvideo einer robotischen Zystenenukleation (bei Verdacht auf eine BD-IPMN mit Worrisome Features) im Pankreaskopf und Processus uncinatus bei einer 62-jährigen Patientin mit besonderer Betonung der wichtigsten vaskulären Landmarken, Besonderheiten der Herangehensweise und Vorteile der robotischen Technik.

Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know

The prevalence of pancreatic cysts has increased significantly over the last decade, partly secondary to increased quality and frequency of cross-sectional imaging. While the majority never progress to cancer, a small number will and need to be followed. The management of pancreatic cysts can be both confusing and intimidating due to the multiple guidelines with varying recommendations. Despite the differences in the specifics of the guidelines, they all agree on several high-risk features that should get the attention of any clinician when assessing a pancreatic cyst: presence of a mural nodule or solid component, dilation of the main pancreatic duct (or presence of main duct intraductal papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology on pancreatic cyst fluid aspiration. Other important criteria to consider include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9 levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related to the cystic lesion.

Free of malignancy but not of fears: A closer look at Damocles syndrome in survivors of hematologic malignancies

Fear of cancer recurrence (FoR) is an important yet underestimated long term sequela that many cancer survivors suffer from. The continuous state of uncertainty the survivors might go through can lead to a serious impact on their quality of life (QoL), which is collectively referred to as Damocles syndrome. Given the increasing numbers of cancer survivors, it is crucial to understand the different psychological issues that face them, including Damocles syndrome. Herein, we review the current literature of Damocles syndrome specifically in hematologic cancer survivors. Although with inconsistent terms, current literature demonstrates the impact and the prevalence of Damocles syndrome on QoL of survivors of leukemia, lymphoma, and hematopoietic cell transplant. Interventional studies are very limited in this area. Moreover, hematologic malignancy survivors can also meet the diagnostic criteria of other psychiatric diseases, including depression, anxiety, and post-traumatic stress disorder, wherein they should be managed accordingly. It is important to increase the awareness about Damocles syndrome and screen patients for it and other related psychological disorders. Additionally, this review has shown the need for standardization of Damocles syndrome definitions. Finally, the lack of interventional studies that target survivors' psychosocial challenges calls for prospective research to better address this rising problem.