Mistakes in pancreatic cystic neoplasms and how to avoid them

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Mistakes in pancreatic cystic neoplasms and how to avoid them

Marco Del Chiaro, Juan Enrique Dominguez-Munoz, Giovanni Marchegiani

Summary

AI Generated

Pancreatic cystic neoplasms are frequent lesions with varying biological behaviour that require tailored management to balance cancer prevention against overtreatment.

Pancreatic cystic neoplasms may be present in 2–45% of the general population and prevalence increases with age
Different types of pancreatic cystic neoplasms range from benign to malignant and require different surveillance and therapeutic approaches
Correct management is critical for avoiding progression to cancer while preventing unneeded follow-up, unnecessary invasive diagnostic procedures, and overtreatment

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Vilela A, Quingalahua E, Vargas A, et al. Global Prevalence of Pancreatic Cystic Lesions in the General Population on Magnetic Resonance Imaging: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. Epub ahead of print 27 February 2024.

Ohtsuka T, Fernandez-del Castillo C, Furukawa T, et al. International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas. Pancreatology 2024; 24: 255–270.

The European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789–804.

Huang C, Prabhu V, Smereka P, et al. Comparison of intra- and inter-reader agreement of abbreviated versus comprehensive MRCP for pancreatic cyst surveillance. Abdom Radiol. Epub ahead of print 18 June 2024.

Udare A, Agarwal M, Alabousi M, et al. Diagnostic Accuracy of MRI for Differentiation of Benign and Malignant Pancreatic Cystic Lesions Compared to CT and Endoscopic Ultrasound: Systematic Review and Meta‐analysis. J Magn Reson Imaging 2021; 54: 1126–1137.

Noia JL, Mejuto R, Oria I, et al. Rapid diagnosis of mucinous cystic pancreatic lesions by on-site cyst fluid glucometry. Surg Endosc 2022; 36: 2473–2479.

Rossi G, Petrone MC, Tacelli M, et al. Glucose and lactate levels are lower in EUS-aspirated cyst fluid of mucinous vs non-mucinous pancreatic cystic lesions. Dig Liver Dis 2024; 56: 836–840.

Khan I, Baig M, Bandepalle T, et al. Utility of Cyst Fluid Carcinoembryonic Antigen in Differentiating Mucinous and Non-mucinous Pancreatic Cysts: An Updated Meta-Analysis. Dig Dis Sci 2022; 67: 4541–4548.

McCarty TR, Garg R, Rustagi T. Pancreatic cyst fluid glucose in differentiating mucinous from nonmucinous pancreatic cysts: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94: 698-712.e6.

10.

Li S, Wang Z, Pan C, et al. Comparative Performance of Endoscopic Ultrasound-Based Techniques in Patients With Pancreatic Cystic Lesions: A Network Meta-Analysis. Am J Gastroenterol 2023; 118: 243–255.

11.

Haeberle L, Schramm M, Goering W, et al. Molecular analysis of cyst fluids improves the diagnostic accuracy of pre-operative assessment of pancreatic cystic lesions. Sci Rep 2021; 11: 2901.

12.

Rift CV, Melchior LC, Kovacevic B, et al. Targeted next-generation sequencing of EUS-guided through-the-needle-biopsy sampling from pancreatic cystic lesions. Gastrointest Endosc 2023; 97: 50-58.e4.

13.

Kirschenbaum JD, Gonda TA. The Use of Integrated Molecular Testing in the Assessment and Management of Pancreatic Cysts. Curr Gastroenterol Rep 2023; 25: 182–190.

14.

Du C, He Z, Gao F, et al. Factors affecting the diagnostic value of liquid-based cytology by EUS-FNA in the diagnosis of pancreatic cystic neoplasms. Endosc Ultrasound 2024; 13: 94–99.

15.

Sigel C, Wei X, Agaram N, et al. Diagnostic features of low‐ and high‐grade mucinous neoplasms in pancreatic cyst FNA cytology. Cancer Cytopathol 2023; 131: 325–336.

16.

Thosani N, Thosani S, Qiao W, et al. Role of EUS-FNA-Based Cytology in the Diagnosis of Mucinous Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Dig Dis Sci 2010; 55: 2756–2766.

17.

Jais B, Rebours V, Malleo G, et al. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 2016; 65: 305–312.

18.

Marchegiani G, Andrianello S, Pollini T, et al. “Trivial” Cysts Redefine the Risk of Cancer in Presumed Branch-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Potential Target for Follow-Up Discontinuation? Am J Gastroenterol 2019; 114: 1678–1684.

19.

Crippa S, Pezzilli R, Bissolati M, et al. Active Surveillance Beyond 5 Years Is Required for Presumed Branch-Duct Intraductal Papillary Mucinous Neoplasms Undergoing Non-Operative Management. Am J Gastroenterol 2017; 112: 1153–1161.

20.

Del Chiaro M, Ateeb Z, Hansson MR, et al. Survival Analysis and Risk for Progression of Intraductal Papillary Mucinous Neoplasia of the Pancreas (IPMN) Under Surveillance: A Single-Institution Experience. Ann Surg Oncol 2017; 24: 1120–1126.

21.

Lee BS, Nguyen AK, Tekeste TF, et al. Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis. Pancreatology 2021; 21: 144–154.

22.

Lisotti A, Napoleon B, Facciorusso A, et al. Contrast-enhanced EUS for the characterization of mural nodules within pancreatic cystic neoplasms: systematic review and meta-analysis. Gastrointest Endosc 2021; 94: 881-889.e5.

23.

Ohno E, Balduzzi A, Hijioka S, et al. Association of high-risk stigmata and worrisome features with advanced neoplasia in intraductal papillary mucinous neoplasms (IPMN): A systematic review. Pancreatology 2024; 24: 48–61.

24.

Fong ZV, Hernandez-Barco YG, Castillo CF. A Clinical Guide to the Management of Intraductal Papillary Mucinous Neoplasms: the Need for a More Graded Approach in Clinical Decision-making. J Gastrointest Surg 2023; 27: 1988–1998.

25.

Fogliati A, Crippa S, Marchegiani G, et al. Implications of pregnancy on MCN of the pancreas: A multicentric case-control study. Pancreatology 2024; 24: 747–752.

26.

Chen J, Beal EW, Pawlik TM, et al. Molecular Diagnosis of Cystic Neoplasms of the Pancreas: a Review. J Gastrointest Surg 2020; 24: 1201–1214.

27.

Berbís MÁ, Godino FP, Rodríguez-Comas J, et al. Radiomics in CT and MR imaging of the liver and pancreas: tools with potential for clinical application. Abdom Radiol 2023; 49: 322–340.

28.

Flammia F, Innocenti T, Galluzzo A, et al. Branch duct-intraductal papillary mucinous neoplasms (BD-IPMNs): an MRI-based radiomic model to determine the malignant degeneration potential. Radiol Med (Torino) 2023; 128: 383–392.

29.

Lee DY, Shin J, Kim S, et al. Radiomics model versus 2017 revised international consensus guidelines for predicting malignant intraductal papillary mucinous neoplasms. Eur Radiol 2023; 34: 1222–1231.

30.

Semaan A, Bernard V, Wong J, et al. Integrated Molecular Characterization of Intraductal Papillary Mucinous Neoplasms: An NCI Cancer Moonshot Precancer Atlas Pilot Project. Cancer Res Commun 2023; 3: 2062–2073.

31.

Aussilhou B, Ftériche FS, Bouquot M, et al. Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula. Surg Endosc 2023; 37: 544–555.

32.

Symeonidis D, Paraskeva I, Samara AA, et al. Central Pancreatectomy: Balancing between the Favorable Functional Results and the Increased Associated Morbidity. Surg J 2024; 10: e20–e24.

33.

Arnelo U, Valente R, Scandavini CM, et al. Intraoperative pancreatoscopy can improve the detection of skip lesions during surgery for intraductal papillary mucinous neoplasia: A pilot study. Pancreatology 2023; 23: 704–711.

34.

Grewal M, Habib JR, Paluszek O, et al. The Role of Intraoperative Pancreatoscopy in the Surgical Management of Intraductal Papillary Mucinous Neoplasms: A Scoping Review. Pancreas 2024; 53: e280–e287.

Abstract

Pancreatic cystic neoplasms (PCN) are a frequent and clinically challenging condition. PCN prevalence increases with age and reports estimate that they may be present in 2–45% of the general population. In addition, the biological behaviour of the various types of PCN differs (ranging from benign to malignant [table 1]), requiring different surveillance and therapeutic approaches. Correct management of PCN is, therefore, critical for avoiding progression to cancer, but at the same time avoiding unneeded close and long-term follow-up, unnecessary invasive diagnostic procedures and overtreatment.

Topics

Digestive Oncology Pancreas

Citation

Domínguez-Muñoz J.E. and Del Chiaro M. Mistakes in pancreatic cystic neoplasms and how to avoid them. UEG Education 2018; 18: 35–37.

Published

2024

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Abstract

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Published

2026

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New

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Mistakes in the management of hepatocellular carcinoma and how to avoid them

Spyridon Pantzios, Ioannis Elefsiniotis, Christos Triantos

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AI Generated

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

The European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789–804.

Noia JL, Mejuto R, Oria I, et al. Rapid diagnosis of mucinous cystic pancreatic lesions by on-site cyst fluid glucometry. Surg Endosc 2022; 36: 2473–2479.

Rossi G, Petrone MC, Tacelli M, et al. Glucose and lactate levels are lower in EUS-aspirated cyst fluid of mucinous vs non-mucinous pancreatic cystic lesions. Dig Liver Dis 2024; 56: 836–840.

10.

11.

Haeberle L, Schramm M, Goering W, et al. Molecular analysis of cyst fluids improves the diagnostic accuracy of pre-operative assessment of pancreatic cystic lesions. Sci Rep 2021; 11: 2901.

12.

Rift CV, Melchior LC, Kovacevic B, et al. Targeted next-generation sequencing of EUS-guided through-the-needle-biopsy sampling from pancreatic cystic lesions. Gastrointest Endosc 2023; 97: 50-58.e4.

13.

Kirschenbaum JD, Gonda TA. The Use of Integrated Molecular Testing in the Assessment and Management of Pancreatic Cysts. Curr Gastroenterol Rep 2023; 25: 182–190.

14.

Du C, He Z, Gao F, et al. Factors affecting the diagnostic value of liquid-based cytology by EUS-FNA in the diagnosis of pancreatic cystic neoplasms. Endosc Ultrasound 2024; 13: 94–99.

15.

Sigel C, Wei X, Agaram N, et al. Diagnostic features of low‐ and high‐grade mucinous neoplasms in pancreatic cyst FNA cytology. Cancer Cytopathol 2023; 131: 325–336.

16.

Thosani N, Thosani S, Qiao W, et al. Role of EUS-FNA-Based Cytology in the Diagnosis of Mucinous Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Dig Dis Sci 2010; 55: 2756–2766.

17.

18.

19.

20.

21.

Lee BS, Nguyen AK, Tekeste TF, et al. Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis. Pancreatology 2021; 21: 144–154.

22.

23.

24.

25.

Fogliati A, Crippa S, Marchegiani G, et al. Implications of pregnancy on MCN of the pancreas: A multicentric case-control study. Pancreatology 2024; 24: 747–752.

26.

Chen J, Beal EW, Pawlik TM, et al. Molecular Diagnosis of Cystic Neoplasms of the Pancreas: a Review. J Gastrointest Surg 2020; 24: 1201–1214.

27.

Berbís MÁ, Godino FP, Rodríguez-Comas J, et al. Radiomics in CT and MR imaging of the liver and pancreas: tools with potential for clinical application. Abdom Radiol 2023; 49: 322–340.

28.

29.

30.

31.

32.

Symeonidis D, Paraskeva I, Samara AA, et al. Central Pancreatectomy: Balancing between the Favorable Functional Results and the Increased Associated Morbidity. Surg J 2024; 10: e20–e24.

33.

34.

Abstract

Liver cancer is the sixth most common cancer and the third leading cause of cancer-related death. Hepatocellular carcinoma (HCC) accounts for about 90% of cases and mostly arises in chronic liver disease, especially cirrhosis. Viral hepatitis remains a leading cause, but alcohol-related disease and MASLD are rising. With immune checkpoint inhibitors transforming HCC management, it is timely to highlight common mistakes across screening, staging, diagnosis and treatment.

Topics

Digestive Oncology Hepatobiliary

Published

2026

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European Interdisciplinary Guidelines on Pain Management in Acute Pancreatitis: UEG, EPC, EDS, ESDO, EAGEN, ESPGHAN, ESGAR, and ESPCG Evidence-Based Recommendations

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Guideline

ABSTRACT

Pain is often the presenting symptom of acute pancreatitis (AP) and has a prognostic significance, with poorly treated pain affecting patient outcomes. Despite this, there are currently no international recommendations for pain management in patients admitted with AP. This current guideline was developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. Nine working groups were formed to develop statements on pain management in AP from admission to discharge. After systematic literature reviews, the evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted using three rounds of Delphi method. The guidelines concluded that acute postoperative pain management guidelines are applicable for treating acute pain due to AP. The numerical rating scale is preferred for pain assessment because of better compliance. Opioids currently form the cornerstone of severe pain management. Potent opioids such as buprenorphine and pentazocine provide superior pain relief over non-opioid medications and decrease the need for rescue analgesia. Current evidence does not consistently demonstrate harm from opioids in AP. In patients with severe pain, safety concerns should not delay the timely use of opioids to ensure adequate pain management. Specific recommendations concerning the use of epidural analgesia, acupuncture and management of pain in the paediatric population and during pregnancy are provided based on evidence and expert opinions. Finally, the unmet needs for future research were discussed and proposed.

Guideline

Clinical Practice Guideline

Topics

Pancreas

Citation

United European Gastroenterology Journal, 2026

Published

2026

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Abstract

Topics

Paediatrics

Published

2025

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Mistakes in the management of peritoneal malignancies and how to avoid them

Francesco Saverio Papadia, Matteo Santoliquido, Andrea Barberis, Tarkan Jäger, Charlotte Rabl

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

The European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789–804.

Noia JL, Mejuto R, Oria I, et al. Rapid diagnosis of mucinous cystic pancreatic lesions by on-site cyst fluid glucometry. Surg Endosc 2022; 36: 2473–2479.

Rossi G, Petrone MC, Tacelli M, et al. Glucose and lactate levels are lower in EUS-aspirated cyst fluid of mucinous vs non-mucinous pancreatic cystic lesions. Dig Liver Dis 2024; 56: 836–840.

10.

11.

Haeberle L, Schramm M, Goering W, et al. Molecular analysis of cyst fluids improves the diagnostic accuracy of pre-operative assessment of pancreatic cystic lesions. Sci Rep 2021; 11: 2901.

12.

Rift CV, Melchior LC, Kovacevic B, et al. Targeted next-generation sequencing of EUS-guided through-the-needle-biopsy sampling from pancreatic cystic lesions. Gastrointest Endosc 2023; 97: 50-58.e4.

13.

Kirschenbaum JD, Gonda TA. The Use of Integrated Molecular Testing in the Assessment and Management of Pancreatic Cysts. Curr Gastroenterol Rep 2023; 25: 182–190.

14.

Du C, He Z, Gao F, et al. Factors affecting the diagnostic value of liquid-based cytology by EUS-FNA in the diagnosis of pancreatic cystic neoplasms. Endosc Ultrasound 2024; 13: 94–99.

15.

Sigel C, Wei X, Agaram N, et al. Diagnostic features of low‐ and high‐grade mucinous neoplasms in pancreatic cyst FNA cytology. Cancer Cytopathol 2023; 131: 325–336.

16.

Thosani N, Thosani S, Qiao W, et al. Role of EUS-FNA-Based Cytology in the Diagnosis of Mucinous Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Dig Dis Sci 2010; 55: 2756–2766.

17.

18.

19.

20.

21.

Lee BS, Nguyen AK, Tekeste TF, et al. Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis. Pancreatology 2021; 21: 144–154.

22.

23.

24.

25.

Fogliati A, Crippa S, Marchegiani G, et al. Implications of pregnancy on MCN of the pancreas: A multicentric case-control study. Pancreatology 2024; 24: 747–752.

26.

Chen J, Beal EW, Pawlik TM, et al. Molecular Diagnosis of Cystic Neoplasms of the Pancreas: a Review. J Gastrointest Surg 2020; 24: 1201–1214.

27.

Berbís MÁ, Godino FP, Rodríguez-Comas J, et al. Radiomics in CT and MR imaging of the liver and pancreas: tools with potential for clinical application. Abdom Radiol 2023; 49: 322–340.

28.

29.

30.

31.

32.

Symeonidis D, Paraskeva I, Samara AA, et al. Central Pancreatectomy: Balancing between the Favorable Functional Results and the Increased Associated Morbidity. Surg J 2024; 10: e20–e24.

33.

34.

Abstract

Peritoneal malignancies represent a complex and often misjudged clinical challenge. Historically synonymous with a terminal diagnosis, the advent of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) radically altered the prognosis for selected patients. However, progress has been jeopardised by a series of recurring and preventable errors in diagnosis, staging, and treatment selection. This article delineates the ten most critical pitfalls in managing peritoneal surface malignancies. For each pitfall, we provide evidence-based explanations, concrete clinical examples, and strategic recommendations for avoidance. We emphasise the pivotal role of early multidisciplinary discussion, precise imaging, and timely referral to high-volume expert centres to optimise patient outcomes and offer curative intent where previously there was none.

Topics

Digestive Oncology Surgery

Published

2026

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ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment

Javier P. Gisbert

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Guideline

Introduction

Ulcerative colitis [UC] is a chronic inflammatory bowel disease [IBD] characterised by colonic inflammation extending to a variable extent from the rectum. Care of the patient with UC requires appropriate input from across the multiprofessional team. These guidelines summarise the recommended medical treatment for adults with UC.

In 2022, the European Crohn’s and Colitis Organisation [ECCO] published new guidelines on the management of UC in two papers focused on the medical and surgical management of the disease.¹^,² For the 2022 UC guidelines, ECCO adopted the Grading of Recommendations Assessment, Development, and Evaluation [GRADE] approach, a systematic process for developing guidelines that addresses how to frame healthcare questions, summarise the evidence, formulate recommendations, and grade their strength and the quality of associated evidence.³ The present paper represents an update to the 2022 guidelines and focuses specifically on the medical management of UC, while a companion paper developed as part of the same process addresses optimal surgical management [ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment].

For this iteration of the guidelines, we have introduced several new, clinically relevant questions selected by members of the guidelines group, alongside a systematic approach to reviewing and updating previous topics to incorporate new evidence and to reappraise all findings within the context of contemporary practice. We have also introduced several “practice points” to summarise evidence and provide expert recommendations in key areas where the evidence remains limited but clinical decisions are still required. In such instances, where application of the GRADE methodology may be impractical, we adopted an approach based on systematic literature review, expert discussion, and voting to reach consensus recommendations outside the formal GRADE process.

Patients living with UC can have a variable disease course.⁴ In this document, we discuss therapeutic approaches stratified by disease severity [mildly-to-moderately active and moderately-to-severely active disease]. Definitions of disease severity are commonly used to establish clinical trial inclusion criteria and may be based on several distinct assessment frameworks.⁵ It is also important to remember that these definitions capture severity at a given point in time and may not reflect the cumulative long-term burden of disease experienced by a patient.⁶

It is also important to consider disease extent when planning treatment in UC, as this may affect the optimal route of drug administration. This is typically defined according to disease involving the rectum only [proctitis], disease distal to the splenic flexure [left-sided or distal UC], or disease extending proximal to the splenic flexure [extensive UC].⁷ It should be noted that disease distribution can change⁴ and that proximal disease extension can be a negative prognostic marker.⁸

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 20, Issue 7, July 2026

Published

2026

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