There’s no question that detection of a pancreatic cyst requires immediate follow-up because of its potential for leading to pancreatic cancer, which is notorious for high mortality rates that have not improved significantly for more than 40 years. But for providers who don’t see many patients with pancreatic cysts, knowing how to assess and manage them, and when it’s best to refer a patient to a gastroenterologist who specializes in pancreatic disorders, isn’t always obvious.
Duke gastroenterologists offer a distinctive multidisciplinary approach to diagnosing and managing pancreatic cysts as soon as they are discovered, utilizing the newest imaging techniques for prompt diagnosis and the combined expertise of gastroenterologists, oncologists, interventional and diagnostic radiologists, and surgical oncologists.
Patient-Centered Referral Experience
The approach means patients don’t need to travel as often for appointments with multiple providers, and care decisions are made by a group of experts in the field of pancreatic conditions. Another benefit for Duke patients is access to cutting-edge clinical trials conducted by internationally recognized researchers who work to develop novel therapeutics for aggressive diseases such as pancreatic cancer.
“Pancreatic cysts are very common—studies report an incidence as high as 20%—and it’s common for an incidental cyst to be found on cross-section imaging that was ordered for an unrelated reason,” says Darshan Kothari, MD, a Duke gastroenterologist who specializes in pancreatic disorders. “When we receive a patient referral, we commit that one of our specialists will see the patient within seven days.”
Kothari explains that initial assessment at Duke involves a review of previous images or patient records by the multidisciplinary team, which determines the best mode of repeat imaging for an individual patient.
“We offer both high-quality pancreatic protocol CT and dedicated MRI imaging,” he says. “We often use contrast-enhanced imaging to better understand a cyst’s characteristics, including irregularity of the cyst wall. Endoscopic ultrasound is commonly used to aspirate tissue and examine a cyst’s cellular data; we also can evaluate the genetics behind a cyst’s cells to help classify it.”
Early Management and Clinical Trial Access
To help guide clinicians in early management of cysts and knowing when to refer patients to a specialist in pancreatic disorders, Kothari says the first thing to know is whether the patient is symptomatic. “Patients presenting with jaundice, weight loss, and acute pancreatitis should prompt referral. Other indications for referral include the size >1.5 cm, irregularities or nodules within a cyst, and widening of the main pancreatic duct. It’s also important to note that even if none of these characteristics are present, our team will be glad to consult with patients simply to allay their fears and help them sleep better at night.”
One clinical trial currently enrolling patients is a multi-institutional effort to perform the first human chemoprevention trial for pancreatic adenocarcinoma. Patients who have undergone partial pancreatectomy and have high-risk intraductal papillary mucinous neoplasms (IPMN) are eligible for this randomized Phase II trial. It will utilize the selective cyclooxygenase (COX) inhibitor sulindac, which has been shown to be highly effective in preventing progression to pancreatic cancer in preclinical models.
Peter J. Allen, MD, a gastrointestinal surgeon and chief of the Surgical Oncology Department, is co-leading the trial. “IPMN represents the only identifiable precursor of pancreatic cancer and presents a great opportunity for us to prevent the development of pancreatic cancer,” he says. “Our previous research has found increased inflammation in the pancreas as these cystic tumors progress to cancer and thus our trial will evaluate whether or not blocking this inflammation can prevent cancer from occurring.”