Pancreatic cystic tumors evaluated by endoscopic ultrasound: Is it multifocal disease?

BACKGROUND AND OBJECTIVES: Pancreatic cystic tumors are detected with increasing frequency globally. One large cross-sectional imaging study showed a prevalence of 25.5% for multifocal cystic tumors. A surgical series showed that single cysts within multifocal disease exhibit independent behavior in molecular and histological analyses. Our study describes the endoscopic ultrasound (EUS) appearance and prevalence of cystic tumors in multifocal disease, which has not previously been studied. METHODS: We report a retrospective analysis of 545 consecutive patients with pancreatic cystic lesions who underwent EUS from January 2010 to July 2015. The patient demographics were 63% females and 37% males, mean age of 67 years, range 21–94. RESULTS: On initial EUS, 315 (58%) of 545 patients had single lesions. 100 (32%) of 315 patients with single lesions had EUS follow-up, and the 11 patients who later developed multifocal disease were not included in our analyses. 230 (42%) of 545 had multiple cystic lesions on initial EUS and comprised our primary analysis. These patients (mean age 71.3) were significantly older (P < 0.05) than patients with single lesions (mean age 64.3). Of the 230 patients with multiple cystic tumors on initial EUS, 145 (63%) were women and 85 (37%) were men. Before EUS, computed tomography (CT) imaging only detected multiple cystic lesions in 16 (7%) of these patients in whom multiple lesions were later diagnosed on EUS. 83 (36%) of patients with multifocal disease had both simple and multilobulated cysts. 154 (67%) of patients with multifocal disease had cysts scattered throughout both the proximal region (uncinate, head, and neck) as well as in the distal region (body/tail) of the pancreas. 34 (15%) of patients with multifocal disease had solid internal nodules. CONCLUSION: Multifocal disease was seen in 42% of patients with cystic tumors evaluated by EUS, due to the increased sensitivity of EUS compared to CT. As cystic tumors are more common in females, multiple cystic tumors are also more common in female patients. The cystic lesions were both complex and simple in appearance on EUS in these patients, with 15% having a solid internal nodule, which has a predisposition for malignancy. As the majority of these patients had cystic lesions scattered throughout the pancreas, we recommend a complete pancreatic examination when performing EUS for pancreatic cysts detected on CT.