Surgical Management of Serous Cystic Neoplasms of the Pancreas

Serous cystic neoplasms (SCNs) account for 30% of all pancreatic cystic neoplasms, occur in middle‐aged women, and are mostly diagnosed incidentally on cross‐sectional imaging performed for other complaints. When present, symptoms (the most common of which is abdominal pain) may be nonspecific. The generally benign nature of SCNs, combined with the substantial morbidity and potential mortality of pancreatic resections, led to a management strategy weighted toward surveillance. However, an initial operative approach is indicated in symptomatic patients or when the diagnosis is uncertain. Despite technical advances, differentiation on imaging between the macrocystic variant of SCNs and mucinous lesions is often difficult, because of a certain degree of morphologic overlap. Endoscopic ultrasound with measurement of carcinoembryonic antigen in the cyst fluid may help to improve the diagnostic accuracy. Giant neoplasms (>10 cm) in the pancreatic head are more likely to exhibit a locally aggressive behavior and also should be resected. Asymptomatic SCNs have been shown to grow very slowly over time (less than 0.3 cm/year) and can be initially managed nonoperatively. In a model assessing predictors of growth, the macrocystic variant and a personal history of other nonpancreatic neoplasms were found to be significant factors, and patients presenting with these two features should be informed about an increased likelihood of resection in the long term. Indications for crossover to surgery during the follow‐up period include the development of symptoms and an unexpected acceleration of growth. The surgical approach has to be tailored according to the location and size of the lesion; atypical and minimally invasive resections can be proposed when feasible. In patients who are poor candidates for surgery, imaging‐guided cyst ablation with ethanol and paclitaxel have shown promising results, despite this approach still being under investigation.