DDSEP Quick Quiz

DDSEP® 8 Quick quiz - December 2017 Question 2

A 55-year-old man was diagnosed with a 3.1-cm cyst in the tail of the pancreas 2 years ago. He had an endoscopic ultrasound–guided fine-needle aspiration at that time and approximately 2 cc of mucinous fluid were aspirated; cyst fluid CEA (carcinoembryonic antigen) was 790 ng/mL and cytology showed a paucicellular specimen with abundant extracellular mucin. The patient was asymptomatic and opted for radiologic surveillance with MRI. On his most recent MRI, the cyst size is currently 3.4 cm. In addition, the MRI notes the presence of an enhancing nodule in the wall of the cyst measuring 5 mm and the pancreatic duct in the tail is mildly dilated to 5 mm. He continues to be asymptomatic and in good health.

What is the most appropriate next step in the management of this patient?

Repeat MRI in 3 months for surveillance

Repeat MRI in 6 months for surveillance

Endoscopic ultrasound–guided fine-needle aspiration (EUS with FNA)

Endoscopic retrograde cholangiopancreatography (ERCP) with brushings

Distal pancreatectomy

Correct Answer: E

Rationale

On serial imaging, two worrisome features have developed in the pancreas cyst, i.e., an enhancing mural nodule and dilation of the main pancreatic duct. These features are high-risk stigmata, and therefore surgical resection is recommended. EUS FNA can be considered but is unlikely to change management if cytology is negative. Radiologic surveillance is not appropriate unless the patient refuses surgery.

Reference

1. Tanaka M., Fernández-del Castillo C., Adsay V., et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12(3):183-97.