Diagnosis and Management of Large Pancreatic Serous Cystadenomas

Abstract

Incidental discovery of pancreatic cysts has increased significantly with advancements in imaging techniques, prompting the need to accurately distinguish benign cysts from those with precancerous or malignant potential. Serous cystic neoplasms, formally known as serous cystadenomas (SCAs), are benign cysts found predominantly in older women and are generally asymptomatic. However, large SCAs (>4 cm) may be symptomatic and exhibit aggressive growth, so it becomes important to diagnose and manage these cysts accurately. Current diagnostic modalities include cross-sectional imaging (CT and MRI scans), cyst fluid analysis, and molecular marker evaluation, with emerging techniques such as radiomics and artificial intelligence-based models showing promise to further enhance diagnostic accuracy. Management strategies for large SCAs (>4 cm) remain variable, with official guidelines and single-institution decisions offering different perspectives regarding criteria for surveillance versus surgical resection. This review explores the diagnostic approaches and evolving management strategies for large SCAs (>4 cm), emphasizing the importance of patient care based on cyst morphology, growth pattern, radiographic findings, clinical presentation, and patient-informed discussions.

Keywords

serous cystadenomas - serous cystic neoplasm - pancreatic cyst - diagnosis - management

Publikationsverlauf

Eingereicht: 17. Oktober 2024

Angenommen: 09. Mai 2025

Artikel online veröffentlicht:
08. Juli 2025

• References

• 1 Ferrone CR, Correa-Gallego C, Warshaw AL. et al. Current trends in pancreatic cystic neoplasms. Arch Surg 2009; 144 (05) 448-454
• 2 Zerboni G, Signoretti M, Crippa S, Falconi M, Arcidiacono PG, Capurso G. Systematic review and meta-analysis: prevalence of incidentally detected pancreatic cystic lesions in asymptomatic individuals. Pancreatology 2019; 19 (01) 2-9
• 3 Schweber AB, Agarunov E, Brooks C, Hur C, Gonda TA. Prevalence, incidence, and risk of progression of asymptomatic pancreatic cysts in large sample real-world data. Pancreas 2021; 50 (09) 1287-1292
• 4 de Jong K, Nio CY, Hermans JJ. et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 2010; 8 (09) 806-811
• 5 Gardner TB, Park WG, Allen PJ. Diagnosis and management of pancreatic cysts. Gastroenterology 2024; 167 (03) 454-468
• 6 Compagno J, Oertel JE. Mucinous cystic neoplasms of the pancreas with overt and latent malignancy (cystadenocarcinoma and cystadenoma). A clinicopathologic study of 41 cases. Am J Clin Pathol 1978; 69 (06) 573-580
• 7 Galanis C, Zamani A, Cameron JL. et al. Resected serous cystic neoplasms of the pancreas: a review of 158 patients with recommendations for treatment. J Gastrointest Surg 2007; 11 (07) 820-826
• 8 Valsangkar NP, Morales-Oyarvide V, Thayer SP. et al. 851 resected cystic tumors of the pancreas: a 33-year experience at the Massachusetts General Hospital. Surgery 2012; 152 (3, Suppl 1): S4-S12
• 9 Jais B, Rebours V, Malleo G. et al. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 2016; 65 (02) 305-312
• 10 Kromrey ML, Bülow R, Hübner J. et al. Prospective study on the incidence, prevalence and 5-year pancreatic-related mortality of pancreatic cysts in a population-based study. Gut 2018; 67 (01) 138-145
• 11 Lee KS, Sekhar A, Rofsky NM, Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol 2010; 105 (09) 2079-2084
• 12 Karoumpalis I, Christodoulou DK. Cystic lesions of the pancreas. Ann Gastroenterol 2016; 29 (02) 155-161
• 13 Tseng JF, Warshaw AL, Sahani DV, Lauwers GY, Rattner DW, Fernandez-del Castillo C. Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg 2005; 242 (03) 413-419 , discussion 419–421
• 14 Khashab MA, Shin EJ, Amateau S. et al. Tumor size and location correlate with behavior of pancreatic serous cystic neoplasms. Am J Gastroenterol 2011; 106 (08) 1521-1526
• 15 Gonda TA, Cahen DL, Farrell JJ. Pancreatic cysts. N Engl J Med 2024; 391 (09) 832-843
• 16 Fernández-del Castillo C, Warshaw AL. Current management of cystic neoplasms of the pancreas. Adv Surg 2000; 34: 237-248
• 17 Santos LD, Chow C, Henderson CJ. et al. Serous oligocystic adenoma of the pancreas: a clinicopathological and immunohistochemical study of three cases with ultrastructural findings. Pathology 2002; 34 (02) 148-156
• 18 Kim HJ, Lee DH, Ko YT, Lim JW, Kim HC, Kim KW. CT of serous cystadenoma of the pancreas and mimicking masses. AJR Am J Roentgenol 2008; 190 (02) 406-412
• 19 Egawa N, Maillet B, Schröder S, Mukai K, Klöppel G. Serous oligocystic and ill-demarcated adenoma of the pancreas: a variant of serous cystic adenoma. Virchows Arch 1994; 424 (01) 13-17
• 20 Chu LC, Singhi AD, Haroun RR, Hruban RH, Fishman EK. The many faces of pancreatic serous cystadenoma: radiologic and pathologic correlation. Diagn Interv Imaging 2017; 98 (03) 191-202
• 21 Brugge WR. Diagnosis and management of cystic lesions of the pancreas. J Gastrointest Oncol 2015; 6 (04) 375-388
• 22 Shah AA, Sainani NI, Kambadakone AR. et al. Predictive value of multi-detector computed tomography for accurate diagnosis of serous cystadenoma: radiologic-pathologic correlation. World J Gastroenterol 2009; 15 (22) 2739-2747
• 23 Lombardo C, Iacopi S, Menonna F. et al. Incidence and reasons of pancreatic resection in patients with asymptomatic serous cystadenoma. Pancreatology 2018; 18 (05) 577-584
• 24 Jones MJ, Buchanan AS, Neal CP, Dennison AR, Metcalfe MS, Garcea G. Imaging of indeterminate pancreatic cystic lesions: a systematic review. Pancreatology 2013; 13 (04) 436-442
• 25 Bassi C, Salvia R, Molinari E, Biasutti C, Falconi M, Pederzoli P. Management of 100 consecutive cases of pancreatic serous cystadenoma: wait for symptoms and see at imaging or vice versa?. World J Surg 2003; 27 (03) 319-323
• 26 Sun HY, Kim SH, Kim MA, Lee JY, Han JK, Choi BI. CT imaging spectrum of pancreatic serous tumors: based on new pathologic classification. Eur J Radiol 2010; 75 (02) e45-e55
• 27 Bhutani MS, Koduru P, Joshi V. et al. EUS-guided needle-based confocal laser endomicroscopy: a novel technique with emerging applications. Gastroenterol Hepatol (N Y) 2015; 11 (04) 235-240
• 28 Giovannini M. Needle-based confocal laser endomicroscopy. Endosc Ultrasound 2015; 4 (04) 284-288
• 29 Napoléon B, Lemaistre AI, Pujol B. et al. A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy 2015; 47 (01) 26-32
• 30 Krishna SG, Hart PA, Malli A. et al. Endoscopic ultrasound-guided confocal laser endomicroscopy increases accuracy of differentiation of pancreatic cystic lesions. Clin Gastroenterol Hepatol 2020; 18 (02) 432-440.e6
• 31 Konjeti VR, McCarty TR, Rustagi T. Needle-based confocal laser endomicroscopy (nCLE) for evaluation of pancreatic cystic lesions: a systematic review and meta-analysis. J Clin Gastroenterol 2022; 56 (01) 72-80
• 32 Sedlack R, Affi A, Vazquez-Sequeiros E, Norton ID, Clain JE, Wiersema MJ. Utility of EUS in the evaluation of cystic pancreatic lesions. Gastrointest Endosc 2002; 56 (04) 543-547
• 33 Kaneto H, Endo T, Ozeki I. et al. Macrocystic serous cystadenoma of the pancreas: importance of co-existent tiny cysts depicted by EUS. J Gastroenterol 2000; 35 (06) 472-475
• 34 Ahmad NA, Kochman ML, Brensinger C. et al. Interobserver agreement among endosonographers for the diagnosis of neoplastic versus non-neoplastic pancreatic cystic lesions. Gastrointest Endosc 2003; 58 (01) 59-64
• 35 Belsley NA, Pitman MB, Lauwers GY, Brugge WR, Deshpande V. Serous cystadenoma of the pancreas: limitations and pitfalls of endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer 2008; 114 (02) 102-110
• 36 Wang X, Zhang X, Hui P, Cai G. Improving diagnostic yield of pancreatic serous cystadenoma with cyst fluid ancillary testing, adjunct immunohistochemistry, and additional fine-needle biopsy sampling. Cancer Cytopathol 2024; 132 (07) 425-434
• 37 Frossard JL, Amouyal P, Amouyal G. et al. Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions. Am J Gastroenterol 2003; 98 (07) 1516-1524
• 38 Abdelkader A, Hunt B, Hartley CP, Panarelli NC, Giorgadze T. Cystic lesions of the pancreas: differential diagnosis and cytologic-histologic correlation. Arch Pathol Lab Med 2020; 144 (01) 47-61
• 39 Brugge WR, Lewandrowski K, Lee-Lewandrowski E. et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126 (05) 1330-1336
• 40 Nagula S, Kennedy T, Schattner MA. et al. Evaluation of cyst fluid CEA analysis in the diagnosis of mucinous cysts of the pancreas. J Gastrointest Surg 2010; 14 (12) 1997-2003
• 41 Simons-Linares CR, Yadav D, Lopez R. et al. The utility of intracystic glucose levels in differentiating mucinous from non-mucinous pancreatic cysts. Pancreatology 2020; 20 (07) 1386-1392
• 42 McCarty TR, Garg R, Rustagi T. Pancreatic cyst fluid glucose in differentiating mucinous from nonmucinous pancreatic cysts: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94 (04) 698-712.e6
• 43 Hawes RH, Clancy J, Hasan MK. Endoscopic ultrasound-guided fine needle aspiration in cystic pancreatic lesions. Clin Endosc 2012; 45 (02) 128-131
• 44 Paniccia A, Polanco PM, Boone BA. et al. Prospective, multi-institutional, real-time next-generation sequencing of pancreatic cyst fluid reveals diverse genomic alterations that improve the clinical management of pancreatic cysts. Gastroenterology 2023; 164 (01) 117-133.e7
• 45 Springer S, Wang Y, Dal Molin M. et al. A combination of molecular markers and clinical features improve the classification of pancreatic cysts. Gastroenterology 2015; 149 (06) 1501-1510
• 46 Lopes Vendrami C, Hammond NA, Escobar DJ. et al. Imaging of pancreatic serous cystadenoma and common imitators. Abdom Radiol (NY) 2024; 49 (10) 3666-3685
• 47 Reid MD, Choi H, Balci S, Akkas G, Adsay V. Serous cystic neoplasms of the pancreas: clinicopathologic and molecular characteristics. Semin Diagn Pathol 2014; 31 (06) 475-483
• 48 Lilo MT, VandenBussche CJ, Allison DB. et al. Serous cystadenoma of the pancreas: potentials and pitfalls of a preoperative cytopathologic diagnosis. Acta Cytol 2017; 61 (01) 27-33
• 49 Dalal V, Carmicheal J, Dhaliwal A, Jain M, Kaur S, Batra SK. Radiomics in stratification of pancreatic cystic lesions: machine learning in action. Cancer Lett 2020; 469: 228-237
• 50 Kurita Y, Kuwahara T, Hara K. et al. Diagnostic ability of artificial intelligence using deep learning analysis of cyst fluid in differentiating malignant from benign pancreatic cystic lesions. Sci Rep 2019; 9 (01) 6893
• 51 Zhang Y, Yao J, Liu F. et al. Radiomics based on contrast-enhanced ultrasound images for diagnosis of pancreatic serous cystadenoma. Ultrasound Med Biol 2023; 49 (12) 2469-2475
• 52 Chu LC, Park S, Soleimani S. et al. Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists. Abdom Radiol (NY) 2022; 47 (12) 4139-4150
• 53 Elta GH, Enestvedt BK, Sauer BG, Lennon AM. ACG clinical guideline: diagnosis and management of pancreatic cysts. Am J Gastroenterol 2018; 113 (04) 464-479
• 54 European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67 (05) 789-804
• 55 Megibow AJ, Baker ME, Morgan DE. et al. Management of incidental pancreatic cysts: a white paper of the ACR incidental findings committee. J Am Coll Radiol 2017; 14 (07) 911-923
• 56 Vege SS, Ziring B, Jain R, Moayyedi P. Clinical Guidelines Committee, American Gastroenterology Association. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148 (04) 819-822 , e12–e13
• 57 Tanaka M, Fernández-Del Castillo C, Kamisawa T. et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17 (05) 738-753
• 58 Malleo G, Bassi C, Rossini R. et al. Growth pattern of serous cystic neoplasms of the pancreas: observational study with long-term magnetic resonance surveillance and recommendations for treatment. Gut 2012; 61 (05) 746-751
• 59 El-Hayek KM, Brown N, O'Rourke C, Falk G, Morris-Stiff G, Walsh RM. Rate of growth of pancreatic serous cystadenoma as an indication for resection. Surgery 2013; 154 (04) 794-800 , discussion 800–802
• 60 Chang JH, Perlmutter BC, Wehrle C. et al. Natural history and growth prediction model of pancreatic serous cystic neoplasms. Pancreatology 2024; 24 (03) 489-492
• 61 Roldán J, Harrison JM, Qadan M. et al. “Evolving trends in pancreatic cystic tumors: a 3-decade single-center experience with 1290 resections”. Ann Surg 2023; 277 (03) 491-497
• 62 Tran KT, Smeenk HG, van Eijck CH. et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004; 240 (05) 738-745
• 63 Wargo JA, Fernandez-del-Castillo C, Warshaw AL. Management of pancreatic serous cystadenomas. Adv Surg 2009; 43: 23-34
• 64 Park M, Lee J, Kim Y. et al. Pancreatic serous cystic neoplasm mimicking intraductal papillary mucinous neoplasm: two case reports and literature review. Medicine (Baltimore) 2023; 102 (05) e32820