UCLA–Veterans
Affairs team develops new tool to help guide pancreatic cyst treatment
As a result of improved
imaging technology, pancreatic cysts are increasingly diagnosed in
asymptomatic
individuals who undergo scans for other reasons. And while most of these
cysts
follow a benign course, a small but significant number are either
malignant at
the time of diagnosis or have the potential to develop into pancreatic
cancer
during a patient’s lifetime.
The dilemma for both
patient and clinician is determining which cysts to leave alone and
which to
surgically remove. Existing treatment guidelines don’t clearly address
many
treatment options beyond the removal of part of the pancreas — a major
undertaking for an asymptomatic lesion.
Now, a UCLA–Veterans
Affairs research team has developed an evaluation tool to help guide
asymptomatic pancreatic cyst treatment. Published in the February issue
of
the journal Gastroenterology, the tool takes into account overall
health, age,
cyst size, surgical risk and patients’ views about quality of
life.
“Surgery may not be
the best initial approach for all patients diagnosed with a specific
pancreatic
cyst. The new tool may help with decision-making and mapping out a
treatment plan,” said study author Dr. Brennan Spiegel, director of the
Education at the David Geffen School of Medicine at UCLA and the VA
Greater Los
Angeles Healthcare System.
The diagnosis of
asymptomatic cysts has increased fivefold over the past decade, due
partly to
an aging population and to improved diagnostics. Current imaging
techniques — including computed tomography (CT), magnetic resonance
imaging (MRI) and endoscopic ultrasound, in which a small camera is
inserted
down the throat and into the stomach and small bowel to image the
pancreas
— combined with pancreatic cyst fluid analysis, offer an 80 percent
accuracy in cyst diagnosis.
“Pancreatic cysts
are most often diagnosed in an older population, and although many are
benign,
these must be carefully tracked, since a small percentage can develop
into
pancreatic cancer,” said study author Dr. James J. Farrell, associate
professor of digestive diseases at the Geffen School of Medicine and
director
of UCLA’s Pancreatic Diseases Program.
Using decision-analysis
software, the research team evaluated a set of hypothetical patients
ranging in
age from 65 to 85 with a variety of asymptomatic pancreatic cysts,
ranging in
size from half a centimeter to greater than 3 cm and located in the head
of the
pancreas, the most common site for branch duct cysts.
The evaluation tool
compared four competing treatment strategies: surgical removal of the
cyst,
annual non-invasive imaging surveillance with MRI or CT, annual
endoscopic
ultrasound and no treatment.
While the tool takes into
account patient age, health, cyst size and surgical risk, it also
considers
whether the patient values overall survival, no matter the quality of
life, or
if he or she prefers balancing quantity and quality of life by pursuing
less
invasive medical measures, which may lead to shorter survival but a
better
quality of life.
The researchers found
that to maximize overall survival, regardless of the quality of life,
surgical
removal was the dominant strategy for a cyst greater than 2 cm, despite
the
patient’s age or other health issues — this is smaller than the 3 cm
threshold supported by current treatment guidelines for surgical
intervention.
Surveillance was the dominant strategy for any cyst less than 1 cm,
which
is similar to current guidelines.
For patients focused on
optimizing both quantity and quality of life, either the “do nothing”
approach or surveillance strategy appeared optimal for those between the
ages
of 65 and 75 with cysts less than 3 cm. For patients over age 85,
non-invasive
surveillance dominated if quality of life was important, most likely
because
surgical benefits are often outweighed by the poor quality of life
experienced
post-operatively in this population.
“The evaluation tool
offers greater insight into not only key risk factors for deciding
pancreatic
cyst treatment but also what patients want and value,” said study author
Dr. Benjamin M. Weinberg, a gastroenterologist in the division of
digestive
diseases at UCLA’s Geffen School of Medicine and the department of
gastroenterology at the VA Greater Los Angeles Healthcare System.
The researchers noted
that data and information on how to use the new evaluation tool are
available
in the study manuscript, and that the tool is ready for use by
clinicians.
Future research aimed at
further understanding the disease process, exploring the rate at which
benign
cysts turn malignant, and delineating the natural history of a malignant
cyst
that doesn’t undergo treatment may also help improve management of
pancreatic
cysts, the researchers said.
“We are learning
more and more about the development and treatment of pancreatic cysts,”
said study author Dr. James S. Tomlinson, assistant professor of
surgical
oncology at UCLA’s Geffen School of Medicine and the department of
surgery at
the VA Greater Los Angeles Healthcare System. “The more prognostic tools
available to assist both the clinician and the patient in the complex
decision-making associated with cystic disease of the pancreas, the more
appropriate the management of this disease.”
The researchers noted
that current management of pancreatic cysts remains uncertain and
challenging.
To date, no prospective
randomized trials have been carried out for this disease. To optimize
individual care, clinicians need evidence-based guidance to help select
between
competing strategies.
The study was funded by a
Veterans Affairs Health Services Research and Development grant, a
Career
Development Transition Award grant, the
National
Institutes of Health career development grant.