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Page 2 Langan et al. Art Int Surg 2023;3:140-6 https://dx.doi.org/10.20517/ais.2023.13

[1]
women, respectively. However, pancreatic cancer was the fourth leading cause of cancer-related mortality .
Currently, over 60,000 Americans are expected to be diagnosed with pancreatic ductal adenocarcinoma
[1]
(PDAC) in 2022, with over 48,000 estimated deaths . Moreover, the median survival for a resected and
[2,3]
multimodal treated PDAC remains 48 months with a 5-year survival rate of 11% for all-comers . Due to
these statistics, efforts have been placed on early identification and intervention. One particular risk factor
which has seen recent increased research and attention is a mucinous pancreatic cyst. This review will
document the risk of mucinous cysts of the pancreas and address an Artificial Intelligence platform that has
been implemented to identify and follow pancreatic cyst patients with the goal of reliably identifying
pancreatic cancer as early as possible.

When assessing the risk for the development of pancreatic cancer, non-modifiable and modifiable risk
factors have been identified. Factors that cannot be mitigated include age (median age at diagnosis is 70
years), male gender, race, family history of pancreatic cancer and inherited genetic alterations such as
BRCA1, BRCA2, PALB2, FAMMM (p16/CDKN2A), familial pancreatitis (PRSS1), HNPCC and Peutz-
Jeghers syndrome (STK11) . However, factors that may be altered, leading to decreased risk, include
[4]
tobacco use, obesity, pancreatitis, diabetes and active management of pancreatic cysts. Although the
propensity to develop a mucinous pancreatic cyst cannot be altered, the identification and appropriate
management certainly can. Due to improvements in modern imaging quality, currently, 2.3% of abdominal
computed tomography (CT) scans and 19.6% of abdominal magnetic resonance imaging (MRI) exams will
incidentally identify a pancreatic cyst . These data are in concordance with the American
[5,6]
Gastroenterological Association which has stated that upwards of 15% of Americans harbor a pancreatic
cyst. Although certain pancreatic cysts can be benign, such as serous cysts or pseudocysts, intraductal
papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms represent pre-malignant tissue and
will be the focus of this review.

Mucinous pancreatic cysts
Numerous challenges are encountered when assessing patients with mucinous pancreatic cysts. First,
mucinous cysts are pre-malignant mucin-producing epithelial tumors that arise from the pancreatic ductal
system . Second, progression from low-grade dysplasia to high-grade dysplasia to invasive cancer is the
[7,8]
[9]
course followed by up to 30% of PDACs . Moreover, most experts believe that IPMN represents a field
defect of the pancreas and that the risk is not only in the area of radiographic IPMN. Pulling this
information together, the crux for pancreatic care teams is the fact that they are faced with the dilemma
between recommending complex surgery which carries morbidity and mortality risk for low-risk IPMN or
recommending observation for those who could possibly be harboring a radiologically occult malignancy.
Extensive uncertainty exists on the true risk of mucinous pancreatic cysts, and as a result, guidelines vary
considerably. Therefore, pancreatic cyst patients need modern identification and surveillance strategies.

Pancreatic cyst guidelines
Currently, there are at least six separate consensus-based guidelines (The European Study Group, The
American Gastroenterological Association, The American College of Radiology, The American College of
Gastroenterology, The International Association of Pancreatology and the Sendai/Fukoaka Consensus
[10]
Criteria) . Although all of these guidelines were designed to assist in the risk stratification of pancreatic
cysts, they are all varied in their recommendations and their target populations . In essence, a lack of
[10]
uniform consensus remains on the true risk of mucinous cysts of the pancreas as well as how to
longitudinally follow these patients. This topic was explored by Heckler et al. in Pancreatology in 2017,
which published a meta-analysis on the accuracy of the Sendai and Fukuoka Consensus Criteria since the
risk of malignancy in branch duct IPMN is controversial . The analysis included 2,710 patients with a
[11]
median age of 63 years. Results found the Sendai criteria had a sensitivity of 56% and specificity of 74% in