Pancreatic cyst (>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 51-year old patient presents to the emergency room with epigastric pain and a CT scan of the abdomen with contrast is ordered.   A 2.7 cm cyst is incidentally found on the pancreas without high risk features.

A 67-year old patient presents to an outpatient clinic with painless jaundice and is sent to the emergency room, at which time a CT scan of the abdomen and pelvis with intravenous contrast is ordered.  A 3.7 cm cyst is incidentally found on the pancreas with high risk features. 

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 greater than 2.5 cm, the recommendations for followup are based on its size and whether or not high risk features are present.  

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  greater than 2.5 cm, the algorithm adjusts the recommendations based on whether or not the cyst has any solid components (i.e. an enhancing nodule 5mm or greater) or mass effect on the main duct (detection of dilated MPD greater than or equal to 10 mm without another cause of obstruction), clinical history that the patient has jaundice (high risk feature), or if the cyst is greater than 4 cm.  For example: 

• If the cyst is greater than 4 cm, a recommendation is made to consider surgical consultation.  

• If the cyst does not have high risk features as defined above and is between 2.6 cm and 4 cm, 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 2.6 cm and 4 cm and there are high risk features as defined above or this cannot be determined, a recommendation is made to perform endoscopic ultrasound with fine needle aspiration (EUS/FNA) and consider surgical consultation. 

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 Greater than 2.5 cm Present

Dilatation of the Main Pancreatic Duct

Detection of Solid Components in the Cyst

Detection of Peripheral calcifications in the Cyst

Detection of Wall Thickening of  the Cyst

Clinical history of Jaundice in the Indication

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

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