At Penn Gastroenterology, diagnosing and managing pancreatic cysts is the goal of a multidisciplinary program led by Nuzhat A. Ahmad, MD, and Charles M. Vollmer, MD. Dr. Ahmad is Associate Director of Endoscopy at the Hospital of the University of Pennsylvania; Dr. Vollmer is Director of Pancreatic Surgery for the Division of Gastrointestinal Surgery.
Pancreatic cystic lesions (PCLs) are a broad group of lesions classified as non-neoplastic or neoplastic. Approximately 80% of all PCLs are non-neoplastic. These lesions include congenital and retention cysts and the pseudocysts.
The pancreatic cystic neoplasms (PCNs) include the serous cystic neoplasm (SCNs), mucinous cystic neoplasms (MCNs), intraductal papillary mucinous neoplasms (IPMNs) and solid-pseudopapillary neoplasm (SPNs). The latter (MCNs, IPMNs, SPNs) carry a risk for malignant transformation, and in the absence of contraindications, are resected in surgically-fit patients. The SCNs, while neoplastic, are generally benign, but may be symptomatic when large.
PCLs are fairly common, and awareness of these cysts has increased dramatically with advances in cross-sectional imaging (i.e., CT, EUS). Imaging alone is rarely sufficient to distinguish non-neoplastic cysts from pancreatic cystic neoplasms, however. Achieving this end often requires comprehensive investigation of physical, biochemical, cytological and genetic characteristics and highly trained clinical personnel, assets typically available only at large, advanced medical centers.
The Penn Pancreatic Cyst Program
The multidisciplinary Penn Pancreatic Cyst Program was founded to address concerns for diagnostic accuracy and the potential under- or over- treatment of evolving premalignant neoplasms. Under the co-direction of Drs. Ahmad and Vollmer, the Program has the goal of improving clinical care for patients with pancreatic disease, as well as promoting research and enhancing the collective education and expertise of specialists in the field.
The Program’s mission is to provide an optimal approach for each patient. Resection plays a significant role for pancreatic cysts determined by biopsy to be cancerous or pre-cancerous. At close to 150/year, Penn Medicine ranks among the top medical centers in the nation for volume of pancreatic resections. When surgery is necessary, outcomes at Penn for major pancreatic surgery are among the best in the nation.
A component of the Program, the Pancreatic Cyst Management Conference meets every other week to offer physicians in the region a single point of access to a collaborative, multidisciplinary team of experts in pancreatic cyst management. At each meeting, physicians from gastrointestinal surgery, gastroenterology, radiology and pathology/cytopathology collaborate on the care of individual patients.
In explaining the Conference, Dr. Ahmad emphasizes its integrative and collaborative processes.
"Physicians submit cases to the Conference for review,” Dr Ahmad says. “A team made up of specialists in gastroenterology, radiology and pathology/cytopathology then arrives at a consensus for diagnosis. This, in turn, leads to the development of a comprehensive treatment plan in consultation with surgeons and others involved in the patient’s care.
The treatment plans developed at the Pancreatic Cyst Program extend into the community to involve patient and family education about pancreatic cyst management, regular and prompt communication with referring providers and long-term surveillance of patients with pancreatic disease. Physicians are also introduced to information about recent translational and clinical research studies to discover new avenues for diagnosis and treatment.
Among the objectives of the Penn pancreatic research team is to work with the Department of Pathology to find better ways to diagnose and differentiate pancreatic cysts and their progression. One result of this collaboration, a study that first appeared in the Spring 2011 edition of the Penn GI News, “Mesothelin: A Potential Biomarker for the Diagnosis of Mucinous Cystic Lesions of the Pancreas,” was reported in the American Journal of Pathology in 2015.
A cell-surface protein, mesothelin (MSLN) is known to be over-expressed in epithelial mesotheliomas, ovarian cancers and specific squamous cell carcinomas. The Penn study sought to determine whether MSLN expression can be used to differentiate and predict the malignant potential of mucinous lesions of the pancreas. As reported in the AJP, MSLN was diffusely and intensely positive in 86% of the pancreatic adenocarcinoma cases, including cystic adenocarcinoma, demonstrating for the first time the protein’s value as a marker for the differential diagnosis of pancreatic cystic neoplasms.
Individuals who may benefit from evaluation at the Penn pancreatic Cyst Program
include patients with newly diagnosed or suspected pancreatic cysts, including:
- Intraductal Papillary Mucinous Neoplasms (IPMN) both main duct and side branch variants
- Serous cystadenomas (SCA)
- Mucinous cystic neoplasms (MCN)
- Pseudopapillary tumors (AKA Frantz tumor, Hamoudi tumor)
- Cystic neuroendocrine tumors
- Pseudocysts secondary to pancreatitis
- Idiopathic pancreatic cysts
- Family history of Von Hippel Landau syndrome
The Pancreatic Cyst Program also welcomes patients seeking second opinions regarding diagnosis or therapy as well as those interested in participating in clinical research studies for pancreatic cysts. For more information, please contact the Penn GI call center at 215-349-8222.