Guidelines: Tempered Response to Incidental CT Findings Best

Lara C. Pullen, PhD

March 27, 2015

New guidelines from the American Gastroenterological Association (AGA) suggest that incidental pancreatic cysts should not undergo aggressive evaluation. The AGA found there is little high-quality evidence to inform the decision to aggressively evaluate this type of incidental finding. Moreover, reports in support of aggressive evaluation are primarily retrospective and do not directly evaluate reduced mortality from pancreatic adenocarcinoma as the key outcome.

"The AGA has taken a bold and welcome stand in backing away from more aggressive previous recommendations," writes Russell P. Harris, MD, MPH, from the University of North Carolina in Chapel Hill, in a commentary on the new guidelines published online March 25 in the Annals of Internal Medicine. He also notes that incidental findings can lead to a cascade of decisions that involve possible risks and benefits.

Abdominal imaging can uncover incidental findings in the kidneys, adrenals, liver, spleen, and pancreas, yet imaging alone is not able to distinguish between malignant and benign cysts. The new AGA guidelines were issued as a response to the rapid growth in the number of sensitive imaging studies and the consequent marked increase in the identification of incidental pancreatic cysts.

The new guidelines address the management of asymptomatic neoplastic pancreatic cysts and represent the official recommendations of the AGA on the management of pancreatic cysts. These guidelines are the first to systematically evaluate the available evidence. The guidelines do not address the management of cysts in symptomatic patients.

The AGA concluded that although pancreatic cysts are common and the incidence increases with age, the likelihood of invasive carcinoma in these cysts is extremely rare. A key component of the management of pancreatic cysts, therefore, is the ability to identify the small minority of cysts that represent early invasive cancer or high-grade dysplasia.

"Thus all of us — specialists, generalists, and patients — are in the difficult position of not finding the correct approach in the evidence. The benefits are uncertain; the harms are clear. Should we aggressively pursue the possibility of benefit hoping to add years to the lives of a few patients, or should we avoid harms by deferring action? Until there is more evidence, the answer will vary with the framework used for examining the potential consequences of an aggressive versus less aggressive strategy," Dr Harris writes in his commentary.

Dr Harris notes that many of the issues considered in the AGA guideline are relevant beyond the management of pancreatic cysts and address how physicians should evaluate and act on diagnostic testing. In addition, he emphasizes that generalists should be thoughtful when ordering sensitive imaging, and that physicians should also consider value when balancing benefits against harms.

Dr Harris has disclosed no relevant financial relationships.

Ann Intern Med. Published online March 25, 2015. Abstract

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