Small, Stable Pancreatic Cysts May Show Reassuring Outcomes

TOPLINE:

Compared with the general population, patients with small, stable cysts without baseline worrisome features or high-risk stigmata did not have an increased risk for high-grade dysplasia (HGD) or pancreatic cancer (PC). Smaller cyst size (< 15 mm) and growth rate less than 2.5 mm/y emerged as reassuring features with a lower risk for progression.

METHODOLOGY:

• This nested study from the PACYFIC-registry collaboration spanning 44 centres across Europe and Northern America evaluated the risk for HGD and PC on the basis of different pancreatic cyst sizes and growth rates.
• A total of 975 patients with neoplastic and undefined pancreatic cysts (median age, 67 years; 65% women) without baseline worrisome features or high-risk stigmata who had either reached the malignant progression (HGD or PC) or undergone surgical resection by the 24-month follow-up were included in this study.
• High-risk stigmata were defined as obstructive jaundice in patients with pancreatic head cysts, an enhancing mural nodule of 5 mm or larger or any solid component, a main pancreatic duct of 10 mm or larger, and suspicious/positive cytology.
• Worrisome features included recent acute pancreatitis, elevated CA19-9 levels in serum (≥ 37 kU/L), new-onset diabetes, an enhancing mural nodule under 5 mm, a thickened or enhancing cyst wall, a main pancreatic duct measuring 5-10 mm, and/or an abrupt calibre change and lymphadenopathy.
• Data on cyst characteristics, such as size and growth (indicated by the difference in size between the first and last follow-up visits), were collected. Overall, 438 patients had a cyst size less than 15 mm and 885 had cyst growth under 2.5 mm/y, and 20 patients developed HGD or PC over a median follow-up duration of 45 months.

TAKEAWAY:

• Patients with smaller cysts (< 15 mm) showed a 1.5-fold lower risk of developing worrisome features or high-risk stigmata than those with larger cysts (≥ 15 mm; adjusted hazard ratio [aHR], 0.7; P = .03).
• Patients with slow-growing cysts (< 2.5 mm/y) had a 2.8-fold lower risk of developing worrisome features or high-risk stigmata (aHR, 0.4; P < .001) and a 25-fold lower risk of developing HGD or PC (aHR, 0.04; P < .001) than those with fast-growing cysts (≥ 2.5 mm/y).
• When considering both cyst size and growth, the absolute risk of developing worrisome features or high-risk stigmata was lowest for those with a baseline cyst size less than 15 mm and growth under 2.5 mm/y.
• Compared with the general population, patients with small, stable cysts without baseline worrisome features or high-risk stigmata did not have an increased risk for HGD or PC (standardised incidence ratio, 1.13; 95% CI, 0.01-6.30).

IN PRACTICE:

“Low‐risk cysts should be a focal point of attention for future studies aiming to alleviate the burden on patients and health care resources by reducing the intensity of follow‐up regimes or even discontinuing surveillance after years of stability,” the authors of the study wrote.

SOURCE:

This study was led by Iris J.M. Levink, Erasmus University Medical Center, Rotterdam, the Netherlands. It was published online on June 18, 2025, in United European Gastroenterology Journal.

LIMITATIONS:

Cyst management was not standardised across centres and determined by the treating physician, potentially introducing variability in treatment approaches. The study may have referral bias as 14 of 30 participating centres were tertiary care facilities. Only 27% of participants had more than 5 years of follow-up, which limited conclusions about long-term surveillance cessation.

DISCLOSURES:

This study did not receive any specific funding. Some authors reported receiving research grants, consulting fees, and support for investigator-initiated studies and having other ties with various sources. One author reported holding stock/stock options with a pharmaceutical company.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.