Differential diagnosis and follow-up of cystic neoplasms of the pancreas: advanced radiologic imaging and cyst fluid analysis

An increasing number of asymptomatic individuals with pancreatic cystic lesions
are being identified because of a more frequent use of sophisticated abdominal
imaging techniques. Cystic lesions of the pancreas comprise of a heterogeneous
group of diagnostic entities, some of which are (virtually) benign such as
inflammatory pseudocyst or serous cystadenoma and, when asymptomatic, do not
require surgical resection. Others have a malignant potential (mucinous cystic
neoplasms or intraductal papillary mucinous neoplasms (IPMN)) and in these
cases surgical resection is indicated. Because of pre-operative difficulties in
characterizing the nature of pancreatic cystic lesions and a cautious
management strategy based on the policy not to withhold a patient from a
rightly indicated resection (pre-malignant and malignant lesions), many
asymptomatic people with truly benign lesions undergo surgery as a consequence.
Therefore, adequate distinction between the various types of pancreatic cystic
lesions should allow for a better selection of patients to prevent patients
with truly benign lesions to be exposed to unnecessary surgery with associated
morbidity and mortality. Techniques that potentially could be of value in the
differentiation include radiologic imaging techniques (MR, viscosity/density
measurements, endosonography) and the use of new biomarkers including
proteomics technology.

To identify new means to improve the differential diagnosis of pancreatic
cystic lesions to guide patient management.

This prospective protocol will incorporate various investigational techniques
such as MR scan, EUS and EUS-FNA (fluid sampling including brush cytology). The
value of the various imaging techniques will assessed by linking imaging
features to the clinical outcome (surgery, follow-up). EUS will be the main
device in order to assess cystic changes and perform follow-up. Additionally,
MR will be used to measure the viscosity/density index of the lesions. Newly
developed EUS brush cytology devices will be used to obtain cytology from the
inner wall of the cyst to be analysed by means of conventional cytology and
EUS-FNA will be employed to sample cyst fluid for biochemical and biomarker
assessment including the use of proteomics.

Main burden of participation is the initially 6-monthly follow-up in which the
subject undergoes repeated endosonographic investigations and blood sampling,
which both are considered low-risk interventions. Major benefits might occur
when a subject doesn*t have to undergo extensive pancreatic surgery, when this
turns to be unnecessary.