- The risk of pancreatic cancer associated with pancreatic cysts increased with a cyst’s number of worrisome or high-risk traits.
- In this study, worrisome traits were far more common than high-risk cystic features.
- A single feature/trait was linked to a 2% risk of developing pancreatic cancer, but three or more increased the risk to almost 20%.
An accumulation of worrisome or high-risk traits in pancreatic cysts increased the likelihood of a subsequent pancreatic cancer diagnosis, a prospective single-center study of more than 200 patients showed.
During almost 3 years of follow-up, a single worrisome or high-risk feature was associated with a 2% risk of developing pancreatic cancer or advanced precancerous features. For patients with three or more concerning traits, the risk increased to almost 20%. Of 185 patients with concerning features, worrisome traits were far more common (>90%) than high-risk traits.
The overall event rates were low for worrisome or high-risk features, and overall survival was 95% during the study period, which precluded identification of specific risk factors associated with the highest risk. However, the impact of multiple concerning traits on subsequent cancer risk can help inform future trials to gain more insight into the relationship, reported Shounak Majumder, MD, of the Mayo Clinic in Rochester, Minnesota, and colleagues in Gastroenterology.
“As of now, what we can say is that it’s the accumulation of the factors that seems to make a difference,” Majumder told MedPage Today. “We realized that worrisome traits are far more common, and what we learned is that if you start stacking these worrisome features, once you get to greater than two, it gets to what we would consider high risk [for pancreatic cancer].”
“Obviously, this is a small study done at a single center, but if this starts getting confirmed and validated in broader settings, then that could become something that’s more practice changing,” he added. “I don’t think this study by itself is going to completely change our practice, but it’s going to inform practice a little bit. If you have multiple worrisome features, that’s a patient you really need to pay attention to, one that you may even want to consider for intervention with surgery.”
Pancreatic cancer is the third leading cause of cancer death in the U.S. and could become the second leading cause by 2030. The high mortality relates directly to the late diagnosis of most cases. Identifying a pathway to earlier diagnosis has proven difficult because many patients have no symptoms until the cancer has become advanced.
Pancreatic cysts occur in up to 18% of the population. Although most of the lesions are precancerous, some progress to cancer, Majumder and colleagues noted. Studies have shown that surgical resection of high-grade dysplasia and early pancreatic cancers can improve outcomes, making early detection a paramount factor in the management of pancreatic cysts. Most of the lesions are asymptomatic and discovered incidentally, posing an obstacle to early detection.
Worrisome or high-risk features of pancreatic cysts increase the likelihood of progression to pancreatic cancer, the authors continued. Although clinical guidelines exist for the management of pancreatic cysts with worrisome or high-risk features, malignancy-related outcomes vary considerably. Much of the existing evidence has come from retrospective studies, often with opportunistic follow-up.
Majumder and colleagues conducted a prospective cohort study to estimate the incidence of advanced neoplasia in consecutive patients with pancreatic cystic lesions with worrisome or high-risk features. They considered a dozen different traits, most of which fell into the worrisome category.
They enrolled 230 patients, of whom 32 had surgery within 3 months. The remaining 198 patients entered clinical surveillance, 93.4% with worrisome features and 6.6% with high-risk pancreatic cysts. Subsequently, 18 patients had surgery, 15 for cysts with worrisome features and three for high-risk cystic lesions. Pathology revealed one case of intraductal papillary mucinous neoplasia (IPMN)-high-grade dysplasia and two stage IA IPMN-derived pancreatic cancers.
The authors found that a single worrisome or high-risk feature was associated with a 2% risk of pancreatic cancer at 3 years, increasing to 4% with two features. For patients whose cysts had three or more worrisome or high-risk features, the risk increased to 18%.
Looking ahead, Majumder said he would like to delve into “what about worrisome is worrisome?”
“That’s an important question that we will need more time and more numbers to delineate more clearly,” he said. “Right now, we know that multiple is worse than single, but there might be certain worrisome features where their singular presence might be as important. That part we haven’t completely figured out.”
“The other part is the need to follow these patients longer,” he added. “This is a substantial cohort because we limited inclusion to the highest risk patients. We could have taken everybody with a pancreatic cyst, but we and others have published on this, and we know that the natural history is not that bad when it comes to cancer, so we can reassure patients.”
