Management of incidentally found pancreatic cysts

The use of advanced imaging technology has contributed to an increased incidence of incidentally found cysts detected in the pancreas (pancreas), ie cysts that are detected when, for example, an imaging is performed for another reason. There are several different types of pancreatic cysts, both benign and those that are or are at risk of developing cancer. Surgical treatment is both costly and risky and a common way to deal with discovered pancreatic cysts is to observe them over time.

Reading time approx. 28 minutes Published: January 14, 2021 Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: January 14, 2021 Report no: ut202101 Registration no: SBU 2020/147

Question

What systematic reviews are there on the management and follow-up of incidentally found cysts in the pancreas?

Identified literature

Table 1. Systematic reviews with low/medium risk of bias.

IPMN = Intraductal pancreatic mucinous neoplasm; BD-IPMN = Branch duct intraductal papillary mucinous neoplasm; NF-PNET = Non-functional pancreatic neuroendocrine tumours; MEN1 = Multiple endocrine neoplasia; FNA = Fine needle aspiration
Included studies	Population/Intervention	Outcome
Vanella et al, 2018 [1]
Search resulted in 1206 identified articles and 15 studies were included in qualitative synthesis and 8 studies in the quantitative synthesis. The 8 studies selected for quantitative synthesis included 556 patients (323 with main-duct/mixed-type IPMNs and 233 with branch-duct IPMNs) Included all study designs but excluded case series with ten or fewer patients.	Population: Individuals with IPMN with at least one worrisome feature or high-risk stigmata who had not undergone surgical resection. Intervention: Surveillance	Overall mortality: 30.9% (95% CI, 19.6 to 45.1) Disease-specific mortality: 11.6% (95% CI, 6.0 to 21.2). Incidence rate of overall mortality per 1000 patient-years: 78 (95% CI, 44 to 111) Incidence rate of disease-specific mortality per 1000 patient-years: 23 (95% CI, 9 to 37) Incidence rate of disease-specific mortality per 1000 patient-years for IPMN in main-duct: 32 (95% CI, 12 to 52) Incidence rate of disease-specific mortality per 1000 patient-years for IPMN in branch-duct: 5 (95% CI, 0 to 10)
Authors’ conclusion: “The present results suggest that a specific subset of patients who have IPMNs with worrisome features or high-risk stigmata are more likely to die from co-morbidities rather than from an IPMN-related cancer. In this particular setting of elderly patients or those with co-morbidities, disease-specific mortality should be carefully balanced against the mortality and morbidity of pancreatic surgery.”
Sallinen et al, 2017 [2]
Search resulted in 5440 identified articles and 9 were included in the review. The 9 studies included a total of 408 patients, whereof 344 with a sporadic neuroendocrine pancreatic tumour and 64 with MEN1-related tumours. Included most study designs, but all included studies in the review were retrospective cohort studies.	Population: Patients with neuroendocrine pancreatic tumours without metastases at the time of diagnosis. Intervention: Surveillance, median follow-up had to be at least 18 months.	Tumor growth (proportion): NF-PNET: 0.22 (95% CI, 0.07 to 0.41) MEN1: 0.52 (95% CI, 0.18 to 0.85) Developed metastasis (proportion): NF-PNET: 0% MEN1: 9% Tumor resection (proportion): NF-PNET: 0.12 (95% CI, 0.04 to 0.23) MEN1: 0.25 (95% CI, 0.04 to 0.54)
Authors’ conclusion: “In conclusion, despite scarce literature with low level of evidence, expectant management of highly selected sporadic small asymptomatic NF-PNETs seems safe. These results should be interpreted with caution as the underlying studies are small retrospective series with only a short follow-up. How to best select patient for surveillance strategy (age, cut-off size, tumor location, imaging features) remains to be clearly determined, and studies with longer follow-up are needed.”
Lensing et al, 2017 [3]
Search resulted in 1357 identified articles and 31 were included in the review. The review included experimental and observational studies, both prospective and retrospective. No RCT’s were found.	Population: Patients (n=8455) with untreated branch-duct intraductal papillary mucinous neoplasms. Intervention: Surveillance, mean range of follow-up were between 7.9 to 120 months.	Increased cyst size (At least 20% increase) Pooled incidence 20% (95% CI, 0.13 to 0,29) Malignant BD-IPMN 3% (95% CI, 0.02 to 0.05) Pancreatic malignancy 2.3% (95% CI, 0.01 to 0.04) Death due to pancreatic malignancy: 0.5% (95% CI, 0.001 to 0.002)
Authors’ conclusion: “The pooled incidences of increased cyst size, malignant BD-IPMN, pancreatic malignancy, and pancreatic malignancy-related death during follow-up were, respectively, 17.4%, 2.5%, 2.6%, and 0.5%.”, “In conclusion, a short-interval follow-up of maximum 6 months seems to be useful and necessary, in order to find these lesions at a resectable time. However, more research is needed to evaluate this in a prospective study.”
Guo et al, 2017 [4]
Search resulted in 1034 identified articles and 6 were included in the review. Included both RCT’s and observational studies. No RCTs were found.	Population: Patients with small (<20 mm) non-functioning pancreatic neuroendocrine tumours. Intervention: Surveillance or resection	Disease-specific survival Three studies showed that both the resection (OP) and observation (OBS) group had 100% disease-specific survival. Overall survival rate: Two studies found that the OBS-group had 100% overall survival and the OP-group had 97% and 100% overall survival (No significant differences). 5-year overall survival One study found that the OP group had a 72.3% to 86% 5-year overall survival while the OBS-group only had 27.6% (P>0.01). Disease progression Three studies presented data on disease progression (No significant differences). OP: 0%; OBS: 3.5% OP: 11%; OBS: 14% OP: 0%; OBS: 0% Surgical death Four studies presented data on surgical death (0%,3%, 0%, 0%). Surgical complications Four studies presented data on surgical complications (46%, 44%, 33% and 35%).
Authors’ conclusion: “After excluding distant metastasis, lymph node metastasis and local invasion on imaging studies, small NF-PNETs can adopt a wait-and-see policy without increase in death and disease progression. More evidences are needed to specify follow-up strategy and whether FNA is required for decision making.”
Choi et al, 2017 [5]
Search resulted in 804 identified articles and 17 were included in the review. Included both observational and experimental studies.	Population: Patients with unresected intraductal papillary mucinous neoplasms (IPMN). Patients were categorised as either low-risk (n=2411) or non-low-risk IPMN (n=825). Low risk was defined as a lack of MPD dilatation (<5mm, or a claim of no MPD) plus a lack of mural nodules. Intervention: Surveillance	Cumulative incidence of pancreatic cancer development. (% (95% CI)) Low-risk patients: 1 year: 0.02 (0.0 to 0.23) 3 year: 1.40 (0.58 to 2.48) 5 year: 3.12 (1.12 to 5.90) 10 year: 7.77 (4.09 to 12.39) Non-low-risk patients 1 year: 1.95 (0.0 to 5.99) 3 year: 5.69 (1.10 to 12.77) 5 year: 9.77 (3.04 to 19.27) 10 year: 24.68 (14.87 to 35.9)
Authors’ conclusion: “In conclusion, low-risk IPMNs had a notable cumulative incidence of pancreatic cancer at 10-year follow-up as the incidence steadily increased linearly with the follow-up duration at constant annual incidence rates of 0.65% to 0.8%/year. Hence, continued long-term surveillance is vital for low-risk IPMNs.”
Crippa et al, 2016 [6]
Search resulted in 2171 identified articles and 20 were include in the review. Included both observational and experimental studies.	Population: Patients (n=2177) with low-risk branch-duct intraductal papillary mucinous neoplasms (BD-IPMN). Low risk was defined as: no symptoms, <30mm, absence of nodules/thick walls, no atypical cells). Intervention: Surveillance, mean follow-up were 29.3 to 76.7 months.	Development of overall pancreatic malignancy: Events/patient-years (pyrs) 0.007/pyrs (95% CI, 0.005 to 0.008) Development of malignant BD-IPMN 0.004/pyrs (95% CI, 0.002 to 0.006) Development of distinct pancreatic ductal adenocarcinoma 0.002/pyrs (95% CI, 0.001 to 0.003) Disease-specific mortality 0.002/pyrs (95% CI, 0.001 to 0.003)
Authors’ conclusion: “In conclusion, in low-risk BD-IPMNs undergoing surveillance the rate of progression to pancreatic malignancies is low (7/1000 pyrs), and the rate of mortality due to pancreatic malignancies is even lower (2/1000 pyrs). These small risks of malignant degeneration and eventual mortality are comparable to the risk of postoperative mortality following pancreatic resection, and therefore prophylactic surgery likely represents an overtreatment. We affirm that nonoperative management of BD-IPMNs without worrisome or high-risk features, as has been suggested in the International Consensus Guidelines, is safe. Based on these data, aggressive management with surgical resection for all BD-IPMNs – including “low-risk” lesions – is not justified.”
Scheiman et al, 2015 [7]
Included both observational and experimental studies, but no RCT’s were found.	Population: Patients with intraductal papillary mucinous neoplasms (IPMN) or mucinous cystic neoplasms (MCN). Intervention: Surveillance or resection	Malignancy in patients undergoing resection 25% (95% CI, 23% to 27%) Postoperative mortality 2.1% (95% CI, 1.5% to 2.7%) Development of invasive neoplasi 2,8% (95% CI, 1,8% to 4%) Postoperative morbidity 30% (95% CI, 25% to 35%)
Authors’ conclusion: “For patients who have benign-appearing lesions with low-risk features on imaging, a decision regarding the patient’s willingness to undergo observation of the lesion should be developed in collaboration with a pancreatic surgeon. In many circumstances, surveillance with noninvasive imaging, typically MRI, and selected use of EUS with or without FNA with cytological analysis and measurement of fluid will allow watchful waiting of a presumed mucinous lesion, including both MCNs and branch duct IPMNs.” “..given the high prevalence of patients with pancreatic cysts and the low rate of malignant transformation over time, this appears to be the most prudent approach to provide patients with the best overall survival”

Table 2. Health economic studies with at least medium quality regarding economic aspects and transferability of economic results.

Included studies	Population/Intervention	Outcome
Aronsson et al, 2018 [8]
Design: Markov model Setting: Sweden Perspective: Healthcare Discount rate: 3% Duration: 35 annual cycles	Population: 65-year-old asymptomatic patient with suspected low-risk intraductal papillary mucinous neoplasms in branch duct (BD-IPMN). Strategies: (1) Upfront total pancreatectomy: BD-IPMN and other benign lesions had no postoperative surveillance. (2) Upfront partial pancreatectomy: BD-IPMN on histopathology had postoperative surveillance with a risk of metachronous PDAC. (3) Initial surveillance: partial pancreatectomy for progressive BD-IPMNs and for cancer found on follow-up (4) Watchful waiting: symptomatic lesions were investigated and underwent partial pancreatectomy if deemed operable.	Incremental cost effectiveness ratio (ICER): Total pancreatectomy: ICER: EUR 167731 per QALY Partial pancreatectomy: ICER: EUR 278696 per QALY Initial surveillance: ICER: EUR 31682 per QALY Watchful waiting: ICER: NA, Base case
Authors’ conclusion: “Our data and other studies support initial surveillance. However, the extension of surveillance, the appropriate interval and type of investigations are not fully investigated. To date, no large comparative prospective studies exist. Future studies will hopefully elucidate this area, as it is apparent that tailored approaches based on more precise risk stratifications are necessary for a safe and cost-effective management of each patient.”
Huang et al, 2010 [10]
Design: Markov model Setting: USA Perspective: Healthcare Discount rate: 3% Duration: 6-month cycles until death.	Population: 60-year-old patient with BD-IPMN in the head of pancreas on either computed tomography (CT) or magnetic resonance imaging (MRI) with or without symptoms. Strategies: (1) Surveillance using consensus guidelines for surgical resection (surveillance strategy), (2) Immediate surgery after initial diagnosis of branch-duct IPMN (surgery strategy) and (3) Surgical resection only on development of symptoms (no surveillance strategy	Incremental cost effectiveness ratio (ICER): Surveillance: ICER: USD 20096 per QALY Surgery: ICER: USD 132436 per QALY No surveillance: ICER: NA, Base case
Authors’ conclusion: “In conclusion, our analysis demonstrates that surveillance with current guidelines is a cost-effective strategy in the management of branch duct IPMN in the head of pancreas when compared to no surveillance. These findings are dependent on the underlying age of the population, specificity and sensitivity of consensus guidelines, and progression from adenoma to dysplasia/CIS. Although surgery could be more effective, it may be prohibitively expensive from a policy perspective.”
Das et al, 2015 [9]
Design: Markov model Setting: USA Perspective: Third-party payer Discount rate: 3% Duration: Cycle length not known, until death.	Population: Asymptomatic patient with an incidentally found 3 cm solitary pancreatic cystic neoplasms. Strategies:strong (1) Wait & watch. Follow all patients, refer for resection only if symptoms occur or worrisome features appear (2) Resect if operable Refer all cysts for resection immediately, no follow-up if patient is inoperable (3) Risk-stratify by EUS + FNA/CEA & cytology ▪ Mucinous: Refer for resection ▪ Non-Mucinous: Follow annually for first 3 years, every 3^rd year thereafter (4) Risk-stratify by EUS + FNA/CEA & cytology & IMP ▪ Non-Mucinous and Mucinous/Benign: Follow annually for first 3 years, every 3^rd thereafter ▪ Mucinous/Indolent: Follow annually for first 5 years, every 3 years thereafter ▪ Mucinous/Aggressive: Refer for resection	Incremental cost effectiveness ratio (ICER): 4. IMP: ICER: USD 62 (Preferred) 3. EUS-FNA+ Cytology +CEA: ICER: USD 6590 (Dominated) 2. Resect if operable: ICER: USD 32054 (Dominated) 1. Wait & watch ICER: NA, base case
Authors’ conclusion: “While current first-line diagnostic tests have lower cost and wider availability, they cannot provide consistent, meaningful prediction of malignant potential. Nevertheless, standard clinical management of patients with PCN relies on these first line tests, the results of which are reflected in Strategy III. Even with the model being heavily biased against IMP, we found that using IMP to predict malignant potential is superior to Strategy III and represents the most cost-effective strategy for managing PCN. These results demonstrate that a reasonably accurate risk stratification tool (e. g., IMP) provides a significant benefit in reducing cost and improving QALY for pancreatic cyst patients.”

References

Vanella G, Crippa S, Archibugi L, Arcidiacono PG, Delle Fave G, Falconi M, et al. Meta-analysis of mortality in patients with high-risk intraductal papillary mucinous neoplasms under observation. British Journal of Surgery 2018;105:328-338.
Sallinen V, Le Large TYS, Galeev S, Kovalenko Z, Tieftrunk E, Araujo R, et al. Surveillance strategy for small asymptomatic non-functional pancreatic neuroendocrine tumors - a systematic review and meta-analysis. HPB : the official journal of the International Hepato Pancreato Biliary Association 2017;19:310-320.
Lensing RJ, Bipat S. Incidences of Pancreatic Malignancy and Mortality in Patients With Untreated Branch-Duct Intraductal Papillary Mucinous Neoplasms Undergoing Surveillance: A Systematic Review. Pancreas 2017;46:1098-1110.
Guo J, Zhao J, Bi X, Li Z, Huang Z, Zhang Y, et al. Should surgery be conducted for small nonfunctioning pancreatic neuroendocrine tumors: a systemic review. Oncotarget 2017;8:35368-35375.
Choi SH, Park SH, Kim KW, Lee JY, Lee SS. Progression of Unresected Intraductal Papillary Mucinous Neoplasms of the Pancreas to Cancer: A Systematic Review and Meta-analysis. Clinical Gastroenterology and Hepatology 2017;15:1509-1520.e4.
Crippa S, Capurso G, Cammà C, Fave GD, Castillo CFD, Falconi M. Risk of pancreatic malignancy and mortality in branch-duct IPMNs undergoing surveillance: A systematic review and meta-analysis. Digestive and Liver Disease 2016;48:473-479.
Scheiman JM, Hwang JH, Moayyedi P. American Gastroenterological Association Technical Review on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts. Gastroenterology 2015;148:824-848.e22.
Aronsson L, Ansari D, Andersson B, Persson U, Fridhammar A, Andersson R. Intraductal papillary mucinous neoplasms of the pancreas - a cost-effectiveness analysis of management strategies for the branch-duct subtype. HPB 2018;20:1206-1214.
Huang ES, Gazelle GS, Hur C. Consensus guidelines in the management of branch duct intraductal papillary mucinous neoplasm: a cost-effectiveness analysis. Digestive diseases and sciences 2010;55:852-60.
Das A, Brugge W, Mishra G, Smith DM, Sachdev M, Ellsworth E. Managing incidental pancreatic cystic neoplasms with integrated molecular pathology is a cost-effective strategy. Endoscopy international open 2015;3:E479-86.

Literature search

PubMed via NLM Maj 6, 2020

Surveillance of pancreatic cysts

The search result, usually found at the end of the documentation, forms the list of abstracts; [MeSH] = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; [MeSH:NoExp] = Does not include terms found below this term in the MeSH hierarchy; [MAJR] = MeSH Major Topic; [TIAB] = Title or abstract; [TI] = Title; [AU] = Author; [TW] = Text Word; Systematic[SB] = Filter for retrieving systematic reviews; * = Truncation
Search terms		Items found
Population:
1.	"pancreatic cyst"[MeSH Terms] OR "pancreatic neoplasms"[MeSH Terms]	80690
2.	"pancreas"[Title/Abstract] OR "pancreatic"[Title/Abstract]	244400
3.	"neoplasm"[Title/Abstract] OR "neoplasms"[Title/Abstract] OR "neoplasm's"[Title/Abstract] OR "cysts"[Title/Abstract] OR "cyst"[Title/Abstract] OR "pseudocyst"[Title/Abstract] OR "pseudocystic"[Title/Abstract] OR "pseudocysts"[Title/Abstract]	393081
4.	"intraductal papillary mucinous neoplasms"[All Fields] OR "mucinous cystic neoplasms"[All Fields] OR "intraductal papillary mucinous tumor"[All Fields] OR "intraductal papillary mucinous neoplasms"[All Fields] OR "serous cystic neoplasms"[All Fields] OR "pseudopapillary neoplasms"[All Fields] OR "solid pseudopapillary neoplasms"[All Fields]	2815
5.	#2 AND #3	21002
6.	#1 OR #4 OR #5	88787 (1057 SR MA)
7.	"incident"[Title/Abstract] OR "coincident"[Title/Abstract] OR "asymptom"[Title/Abstract] OR "Unexpected"[Title/Abstract] OR "unintend"[Title/Abstract] OR "unintention*"[Title/Abstract] OR "Unplanned"[Title/Abstract] OR "Unforeseen"[Title/Abstract] OR "asymptomatic diseases"[MeSH Terms] OR "incidental findings"[MeSH Terms]	426353
8.	#6 AND #7	2758 (34 SR or MA)
Intervention:
9.	"referral"[Title/Abstract] OR "referrals"[Title/Abstract]	110464
10.	"referral and consultation"[MeSH Terms]	74155
11.	"surveilance"[Title/Abstract] OR "surveillances"[Title/Abstract] OR "surveilled"[Title/Abstract] OR "surveillence"[Title/Abstract]	436
12.	"conservative treatment"[MeSH Terms] OR "conservative treatment"[Title/Abstract] OR "conservative management"[Title/Abstract] OR "conservative treatments"[Title/Abstract] OR "wait and see"[Title/Abstract]	47229
13.	#9 OR #10 OR #11 OR #12	208503
Combined sets:
14.	#6 AND #7	2758 (23 SR or MA)
15.	#6 AND #13	999 (7 SR or MA)
16.	#14 OR #15	3651 (34 SR or MA)
Study types:
17.	#6 SR	634
18.	#6 MA	762
19.	#6 GL	159
20.	#6 SR MA GL	1211
21.	#14 SR or MA	23
22.	#14 GL	8
23.	#15 SR or MA	7
24.	#15 GL	3
25.	#16 SR or MA	34
26.	#16 GL	10
Final	#20	1211

Cochrane Library via Wiley May 12, 2020

Surveillance of pancreatic cysts

The search result, usually found at the end of the documentation, forms the list of abstracts.; au = Author; mh = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; mh ^ = Does not include terms found below this term in the MeSH hierarchy; :ti = Title; :ab = Abstract; :kw = Keyword; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; NEAR/# = terms next to each other (number defines how far away terms may be found, irrespective order); CDSR = Cochrane Database of Systematic Review; CENTRAL = Cochrane Central Register of Controlled Trials, “trials”; CRM = Method Studies; DARE = Database Abstracts of Reviews of Effects, “other reviews”; EED = Economic Evaluations; HTA = Health Technology Assessments
Search terms		Items found
Population:
1.	MeSH descriptor: [Pancreatic Cyst] explode all trees	37
2.	MeSH descriptor: [Pancreatic Neoplasms] explode all trees	1687
3.	(pancrea* NEAR/3 cyst*):ti,ab,kw	177
4.	(pancrea* NEAR/3 neoplasm*):ti,ab,kw	1845
5.	intraductal papillary mucinous neoplasm*	63
6.	mucinous cystic neoplasm*	34
7.	intraductal papillary mucinous tumor*	58
8.	serous cystic neoplasm*	20
9.	serous cystadenoma*	16
10.	pseudopapillary neoplasm*	9
11.	#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10	2123
Qualifier: incidental find or asymptomatic
12.	MeSH descriptor: [Incidental Findings] explode all trees	24
13.	incidentaloma*	31
14.	(((incident* or coincident* or unexpected* or uninten* or unplanned or unforeseen or secondary or ancillary or addition* or serendipit) NEAR/2 (find or found or diagnos*))):ti,ab,kw	4036
15.	MeSH descriptor: [Asymptomatic Diseases] explode all trees	190
16.	(((no or non or without or "not") NEAR/3 symptom*)):ti,ab,kw	14056
17.	(asymptom* or presymptomatic or pre-symptomatic or non-symptomatic):ti,ab,kw	10262
18.	#12 or #13 or #14 or #15 or #16 or #17	27570
Intervention: surveillance
19.	MeSH descriptor: [Watchful Waiting] explode all trees	292
20.	MeSH descriptor: [Conservative Treatment] explode all trees	117
21.	(watchful waiting or "wait and see" or surveil*):ti,ab,kw	8547
22.	(treat* NEAR/2 conservativ*):ti,ab,kw	5457
23.	(manage* NEAR/2 conservativ):ti,ab,kw	0
24.	#19 or #20 or #21 or #22 or #23	13946
Outcome: health economy
25.	[mh ^Economics]	38
26.	[mh "Costs and Cost Analysis"] OR [mh "Economics, nursing"] OR [mh "Economics, Medical"] OR [mh "Economics, Pharmaceutical"] OR [mh "Economics, Hospital"] OR [mh "Economics, Dental"] OR [mh "Fees and Charges"] OR [mh Budgets] OR [mh "monte carlo method"] OR [mh "Decision Theory"]	10673
27.	(budget* OR economic* OR cost OR costs OR costly OR costing OR price OR prices OR pricing OR pharmacoeconomic* OR pharmaco-economic* OR expenditure OR expenditures OR expense OR expenses OR financial OR finance OR finances OR financed OR value for money OR monetary value* OR models, economic OR economic model* OR markov chains OR markov OR monte carlo OR decision tree* OR decision analy* OR decision model*):ti,ab,kw	96308
28.	#25 OR #26 OR #27	96323
Combined sets:
29.	#18 OR #24	40891
30.	#18 AND #24	625
31.	#11 AND #18	38
32.	#11 AND #24	29
33.	#11 AND #29 (#18 OR #24)	67
34.	#11 AND #30 (#18 AND #24)	0
35.	#11 AND #18 AND #28	2
36.	#11 AND #24 AND #28	4
37.	#11 AND #29 AND #28	6
38.	#11 AND #30 AND #28	0
Study types: #33 (#37)
39.	Cochrane Reviews	3 (1)
40.	Trials	64 (5)
Final	#33 OR #37	67

Embase via embase.com May 13, 2020

Surveillance of pancreatic cysts

/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :kw = author defined key word; :ti,ab, = Title or abstract or key word; * = Truncation; ’ ’ = Citation Marks; searches for an exact phrase
Search terms		Items found
Population: pancreatic cysts
1.	'pancreas cyst'/exp	12369
2.	'pancreas tumor'/exp	151870
3.	(pancrea* NEAR/3 cyst*):ab,ti,kw	10314
4.	(pancrea* NEAR/3 neoplasm*):ab,ti,kw	10050
5.	'intraductal papillary mucinous tumor'/exp OR 'intraductal papillary mucinous tumor'	6223
6.	'intraductal papillary mucinous neoplasm'/exp OR 'intraductal papillary mucinous neoplasm'	6469
7.	'mucinous cystic neoplasm'/exp OR 'mucinous cystic neoplasm'	1732
8.	'serous cystic neoplasm'/exp OR 'serous cystic neoplasm'	199
9.	'serous cystadenoma'/exp OR 'serous cystadenoma'	9047
10.	'pseudopapillary neoplasm'	663
11.	#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10	170628
Qualifier: incidental find or asymptomatic
12.	'incidental findings'/exp	17120
13.	'incidentaloma'/exp OR 'incidentaloma'	3369
14.	(incident* OR coincident* OR unexpected* OR uninten* OR unplanned OR unforeseen OR secondary OR ancillary OR addition* OR serendipit) NEAR/2 (find OR found OR diagnos*)	118096
15.	'asymptomatic disease'/exp OR 'asymptomatic disease'	14981
16.	((no OR non OR without) NEAR/3 symptom*):ab,kw,ti	103541
17.	presymptomatic OR 'pre symptomatic' OR 'non symptomatic':ab,kw,ti	8943
18.	#12 OR #13 OR #14 OR #15 OR #16 OR #17	243293
Intervention: surveillance
19.	'conservative treatment'/exp OR 'conservative treatment'	609396
20.	'watchful waiting'/exp OR 'watchful waiting'	6344
21.	'wait and see':ti,ab,kw OR surveil*:ti,ab,kw	248564
22.	(treat* NEAR/2 conservativ*):ti,ab,kw	62193
23.	(manage* NEAR/2 conservativ*):ti,ab,kw	34848
24.	#19 OR #20 OR #21 OR #22 OR #23	886276
Outcome: health economy
25.	'economics'/mj OR 'costs and cost analysis'/exp OR ('health economics'/exp OR 'health economics') OR ('pharmacoeconomics'/exp OR 'pharmacoeconomics') OR 'budget'/exp OR budget:ti,ab,kw OR (economic:ti,kw OR cost:ti,kw OR costs:ti,kw OR costly:ti,kw OR costing:ti,kw OR price:ti,kw OR prices:ti,kw OR pricing:ti,kw OR pharmacoeconomic:ti,kw OR 'pharmaco economic':ti,kw OR expenditure:ti,kw OR expenditures:ti,kw OR expense:ti,kw OR expenses:ti,kw OR financial:ti,kw OR finance:ti,kw OR finances:ti,kw OR financed:ti,ab,kw) OR (cost* NEAR/2 (effective* OR utilit* OR benefit* OR minimi* OR analy* OR outcome OR outcomes)):ab,kw OR (value NEAR/2 (money OR monetary)):ti,ab,kw OR (statistical AND 'model'/exp) OR 'economic model':ab,kw OR 'economic model'/exp OR 'probability'/exp OR 'markov chain'/exp OR 'markov':ti,ab,kw OR 'monte carlo method'/exp OR 'monte carlo':ti,ab,kw OR 'decision theory'/exp OR 'decision tree'/exp OR (decision* NEAR/2 (tree* OR analy* OR model*)):ti,ab,kw	1582958
Combined sets:
26.	#18 OR #24 (qual or intervention)	1116727
27.	#18 AND #24 (qual and intervention)	12842
28.	#11 AND #18	3352
29.	#11 AND #24	10622
30.	#11 AND #26	13539
31.	#11 AND #27	435
32.	#25 AND #28	103
33.	#25 AND #29	659
34.	#25 AND #30	736
35.	#25 AND #31	26
Study types:
36.	#30 AND ('meta analysis'/de OR 'meta analysis topic'/de OR 'systematic review'/de OR 'systematic review topic'/de)	371
37.	#34 AND ('meta analysis'/de OR 'meta analysis topic'/de OR 'systematic review'/de OR 'systematic review topic'/de)	39
38.	#30 AND 'practice guideline'/de	486
39.	#31	7
40.	#35	2
41.	#36 OR #37 OR #38	822
Final	#9	822

Medline via OVID 11 maj 2020

Surveillance of pancreatic cysts

The search result, usually found at the end of the documentation, forms the list of abstracts.; sh = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; tw = Title; ab = Abstract; tw = Text Word; kf = keyword heading word; sh = Medline controlled vocabulary Subject Heading (MeSH); $ = Truncation; adj = adjacent (number defines how far away terms may be found, irrespective order)
Search terms		Items found
Population: pancreatic cysts
1.	(pancreatic cyst or pancreatic intraductal neoplasms or pancreatic neoplasms).sh.
2.	(pancrea$ adj3 cyst$).ab,kf,ti.	75639
3.	(pancrea$ adj3 neoplasm$).ab,kf,ti.	7376
4.	intraductal papillary mucinous neoplasm$.ab,kf,sh,ti,tw.	6976
5.	mucinous cystic neoplasm$.ab,kf,sh,ti,tw.	2501
6.	intraductal papillary mucinous tumor$.ab,kf,sh,ti,tw.	885
7.	serous cystic neoplasm$.ab,kf,sh,ti,tw.	400
8.	serous cystadenoma$.ab,kf,sh,ti,tw.	165
9.	pseudopapillary neoplasm$.ab,kf,sh,ti,tw.	506
10.	1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9	8101
Qualifier: incidental find or asymptomatic
11.	(incidental findings).sh.	10171
12.	incidentaloma$.ab,kf,ti,tw.	2190
13.	((incident$ or coincident$ or unexpected$ or uninten$ or unplanned or unforeseen or secondary or ancillary or addition$ or serendipit$) adj2 (find$ or found or diagnos$)).ab,kf,ti.	78559
14.	asymptomatic diseases.sh.	5688
15.	((no or non or without or "not") adj3 symptom$).ab,kf,ti.	94332
16.	asymptom$.ab,kf,ti.	153460
17.	(presymptomatic or pre-symptomatic or non-symptomatic).ab,kf,ti.	5882
18.	or/11-17	327464
Intervention: surveillance
19.	(watchful waiting or conservative treatment).sh.	6497
20.	(watchful waiting or "wait and see" or surveil$).ab,kf,ti.	181830
21.	(treat$ adj2 conservativ$).ab,kf,ti.	44765
22.	(manage$ adj2 conservativ$).ab,kf,ti.	23245
23.	or/19-22	248250
Outcome: health economy
24.	Economics/	27179
25.	exp "Costs and Cost Analysis"/	234930
26.	Economics, Nursing/	3997
27.	Economics, Medical/	9069
28.	Economics, Pharmaceutical/	2928
29.	exp Economics, Hospital/	24410
30.	Economics, Dental/	1911
31.	exp "Fees and Charges"/	30210
32.	exp Budgets/	13670
33.	budget*.ti,ab,kf.	29288
34.	(economic* or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic* or pharmaco-economic* or expenditure or expenditures or expense or expenses or financial or finance or finances or financed).ti,kf.	226155
35.	(economic* or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic* or pharmaco-economic* or expenditure or expenditures or expense or expenses or financial or finance or finances or financed).ab. /freq=2	286317
36.	(cost* adj2 (effective* or utilit* or benefit* or minimi* or analy* or outcome or outcomes)).ab,kf.	160429
37.	(value adj2 (money or monetary)).ti,ab,kf.	2355
38.	exp models, economic/	14886
39.	economic model*.ab,kf.	3286
40.	markov chains/	14162
41.	markov.ti,ab,kf.	22181
42.	monte carlo method/	28127
43.	monte carlo.ti,ab,kf.	48656
44.	exp Decision Theory/	11954
45.	(decision* adj2 (tree* or analy* or model*)).ti,ab,kf.	23598
46.	Or/24-45	722336
Combined sets:
47.	18 OR 23	564984
48.	18 AND 23	10730
49.	10 AND 18	2239
50.	10 AND 23	1497
51.	10 AND 47 (18 OR 23)	3510
52.	10 AND 48 (18 AND 23)	226
53.	10 AND 18 AND 46	40
54.	10 AND 23 AND 46	53
55.	10 AND 47 AND 46	79
56.	10 AND 48 AND 46	14
Study types: systematic reviews, meta-analysis, health technology assessment, CADTH 51(55)
57.	meta-analysis.pt.	114447
58.	meta-analysis/ or systematic review/ or meta-analysis as topic/ or "meta analysis (topic)"/ or "systematic review (topic)"/ or exp technology assessment, biomedical/	215363
59.	((systematic* adj3 (review* or overview)) or (methodologic adj3 (review* or overview*))).ti,ab,kf,kw.	187276
60.	((quantitative adj3 (review* or overview* or synthes)) or (research adj3 (integrati or overview*))).ti,ab,kf,kw.	10812
61.	((integrative adj3 (review* or overview)) or (collaborative adj3 (review or overview)) or (pool adj3 analy*)).ti,ab,kf,kw.	26316
62.	(data synthes* or data extraction* or data abstraction*).ti,ab,kf,kw.	26553
63.	(handsearch* or hand search*).ti,ab,kf,kw.	9181
64.	(mantel haenszel or peto or der simonian or dersimonian or fixed effect* or latin square*).ti,ab,kf,kw.	26027
65.	(meta regression* or metaregression*).ti,ab,kf,kw.	8676
66.	(meta-analy* or metaanaly* or systematic review* or biomedical technology assessment* or bio-medical technology assessment*).mp,hw.	301780
67.	(met analy* or metanaly* or technology assessment* or HTA or HTAs or technology overview* or technology appraisal*).ti,ab,kf,kw.	9281
68.	(medline or cochrane or pubmed or medlars or embase or cinahl).ti,ab,hw.	217438
69.	(cochrane or (health adj2 technology assessment) or evidence report).jw.	19447
70.	(meta-analysis or systematic review).mp.	280907
71.	(comparative adj3 (efficacy or effectiveness)).ti,ab,kf,kw.	13387
72.	(outcomes research or relative effectiveness).ti,ab,kf,kw.	9286
73.	((indirect or indirect treatment or mixed-treatment) adj comparison*).ti,ab,kf,kw.	2148
74.	or/57-73	462293
75.	51 and 74	112
76.	55 and 74	11
Study types: guidelines, CADTH
77.	exp clinical pathway/	6661
78.	exp clinical protocol/	166304
79.	exp consensus/	12673
80.	exp consensus development conference/	11915
81.	exp consensus development conferences as topic/	2824
82.	critical pathways/	6661
83.	exp guideline/	33859
84.	guidelines as topic/	39524
85.	exp practice guideline/	26924
86.	practice guidelines as topic/	116733
87.	health planning guidelines/	4081
88.	(guideline or practice guideline or consensus development conference or consensus development conference, NIH).pt.	43181
89.	(position statement* or policy statement* or practice parameter* or best practice*).ti,ab,kf,kw.	32684
90.	(standards or guideline or guidelines).ti,kf,kw.	109062
91.	((practice or treatment* or clinical) adj guideline*).ab.	39552
92.	(CPG or CPGs).ti.	5703
93.	consensus*.ti,kf,kw.	25901
94.	consensus*.ab. /freq=2	24982
95.	((critical or clinical or practice) adj2 (path or paths or pathway or pathways or protocol*)).ti,ab,kf,kw.	20038
96.	recommendat*.ti,kf,kw.	40644
97.	(care adj2 (standard or path or paths or pathway or pathways or map or maps or plan or plans)).ti,ab,kf,kw.	58085
98.	(algorithm* adj2 (screening or examination or test or tested or testing or assessment* or diagnosis or diagnoses or diagnosed or diagnosing)).ti,ab,kf,kw.	7544
99.	(algorithm* adj2 (pharmacotherap* or chemotherap* or chemotreatment* or therap* or treatment* or intervention*)).ti,ab,kf,kw.	9728
100.	or/77-99	609210
101.	51 and 100	244
102.	55 and 100	12
Limits: Economic
103.	Limit 51 to ("economics (best balance of sensitivity and specificity)" or "costs (best balance of sensitivity and specificity)")	97
104.	55 or 103	109
Final	75 OR 101 (HE)	346 (22)
	104 (SR, MA, HTA or GL)	109 (29)

Page published January 14, 2021

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