Pancreatic Cyst (1.5 - 2.5 cm) Detection with Recommendations for Management on CT

Value Proposition

Incidentally discovered pancreatic cysts can be a challenging diagnostic conundrum for radiologists.  Standardizing the recommendations for followup and workup of these findings serves to help guide clinicians and ordering providers in a more reliable way and can potentially allow a data set to be created that allows research committees to modify the guidelines around incidentally discovered pancreatic cysts.  Upon discovering a pancreatic cyst, these guidelines proposed in the article Management of Incidental Pancreatic Cysts:  A White Paper of the ACR Incidental Findings Committee, 2017 will serve to offer a standardized and efficient approach to categorizing the incidental pancreatic cyst and the recommendations for follow-up .

Narrative(s)

A 58-year old patient presents with acute trauma and is taken to the emergency room at which time a CT scan of the abdomen with contrast is ordered.   A 2.0 cm cyst is incidentally found on the pancreas.

A 46-year old patient presents to an outpatient clinic with right lower quadrant pain and is sent to the emergency room, at which time a CT scan of the abdomen and pelvis with intravenous contrast is ordered.  A 1.7 cm cyst is incidentally found on the pancreas. 

Workflow Description

The relevant images are obtained from modality and sent to PACS and the AI engine based on anatomic landmarks.  The images are analyzed by the engine.  The system then detects the relevant outputs providing associated categorical data, density, and measurements.  An alert message is sent to PACS from the engine with the information, identification, and graphics highlighting the pancreatic lesion, and the density of the pancreatic lesion.  If it is a cyst measuring between 1.5 - 1.9 cm or between 2.0 and 2.5 cm, the recommendations for followup are based on its communication with the main pancreatic duct (MPD).  

An algorithm evaluates the CT scan and categorizes whether a pancreatic lesion is present, absent, or undetermined. If present, it then measures the density of the lesion in Hounsfield units; assesses whether it is a cyst with Hounsfield units measuring less than 20, a solid lesion with Hounsfield units measuring greater than 30, or indeterminate with Hounsfield units between 20 and 30.  If the lesion is solid or indeterminate, then additional imaging is recommended.  If a cyst is determined to be present, the algorithm measures the size.  

If the size is  between 1.5 - 1.9 cm or between 2.0 and 2.5 cm, the algorithm adjusts the recommendations based on whether there is communication with the main pancreatic duct (MPD).  For example: 

• If the cyst is between 1.5 - 1.9 cm and there is communication with the MPD, a recommendation is made to reimage every year for 5 years, then every 2 years for 2 years is made to assess for stability.  

• If the cyst is between 2.0 - 2.5 cm and there is communication with the MPD, a recommendation is made to reimage every 6 months x 4, then every year for 2 years, then every 2 years x 3 OR perform endoscopic ultrasound with fine needle aspiration (EUS/FNA).   

• If the cyst is between 1.5 and 2.5 cm and there is NO communication with the MPD , a recommendation is made to reimage every 6 months x 4, then every year for 2 years, then every 2 years x 3 OR perform endoscopic ultrasound with fine needle aspiration (EUS/FNA).   . 

These recommendations are first suggested to the radiologist for sign off and once the case is approved, they are available to the ordering provider within the report.  These recommendations are based on the article, Management of Incidental Pancreatic Cysts:  A White Paper of the ACR Incidental Findings Committee, 2017.  

Inputs

DICOM Study

Primary Outputs

Pancreatic Lesion Detection

Pancreatic Lesion Measurement

Pancreatic Lesion Density Measurement

Pancreatic Lesion Categorization

Secondary Outputs

Pancreatic Cyst Measuring 1.5 -2.5 cm Present

Communication with the Main Pancreatic Duct

• Further evaluation of the solid pancreatic lesion with follow up recommendations. 

• Evaluation of the peripancreatic fat for stranding to assess for pancreatitis and peripancreatic collections.