Frequent MRIs and cancer surveillance cause patient anxiety
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DEAR DR. ROACH: I'm writing to seek your perspective on a diagnosis that has caused me significant anxiety. A recent incidental finding on an MRI, followed by an endoscopic ultrasound, revealed a cluster of several small cysts (3-7 mm) in my pancreas. They're sus- pected to be branch-duct intraductal papillary mucinous neoplasms (IPMNs). My main pancreatic duct is mildly enlarged.
My doctors have recommended an MRI/MRCP with and without con- trast in six months, followed by ongo- ing monitoring every six months to two years. I've been told that IPMNs are precancerous but usually don't prog- ress to cancer. The thought of fre- quent, lengthy MRIs and long-term cancer surveillance is overwhelming.
Is this intense level of monitoring truly necessary for cysts that are this small, or is it overly aggressive? Are there any safe alternatives such as shorter, non-contrast scans to help me manage the burden of testing? I'd deeply appreciate any guidance you can provide on how to balance medical safety with peace of mind. -- J.D.
ANSWER: As you say, IPMNs can progress to pancreatic cancer, which is why your doctors want to keep a care- ful eye on them. There are several guidelines on the management of these cysts. The main risk factor in develop- ing cancer is the size of the cyst; how- ever, a dilated main pancreatic duct is also a worrisome feature, according to the guidelines.
Because of the dilated duct, the risk for developing cancer in the next five years is about 10%. Even though this means that 90% of the time you won't develop cancer, doctors can find and potentially cure one person for every 10 people who agree to a careful follow- up.
CT scans aren't as accurate and have the downside of ionizing radiation. I do understand that MRIs do take a long time (and can be very noisy), but your risk is high enough that I'd add my recommendation to your doctors' to get the follow-up scans.
You should also get CA19-9 blood
testing. If the main pancreatic duct enlarges over time (by more than 2 mm per year), then it's time to consult a surgeon. It's your body and your choice; however, an MRI is a time- consuming but safe way of checking the stability of these cysts.
DR. ROACH WRITES: A recent column on vertigo led many readers to question whether the reader had Meniere's disease, rather than benign paroxysmal positional vertigo (BPPV). The information provided wasn't enough to be sure, but the reader noted that a BPPV diagnosis had been con- firmed.
There are several ways that a clini- cian can help separate these two diag- noses. In people with BPPV, vertigo is usually triggered by a change in head position; whereas with Meniere's, ver- tigo is spontaneous. Attacks last for seconds to at most 1 minute in BPPV, but with Meniere's, they can last for 20 minutes up to 12 hours.
In addition, Meniere's disease causes hearing loss, which isn't always noticed by the patient. Tinnitus and a sense of fullness in the ear are common with Meniere's. Maneuvers that are done by clinicians in the office can also help separate the conditions.
People can also have both BPPV and Meniere's, which complicates things. When I'm not certain, I often order audiology testing or send my patient to an expert in the diagnosis and treat- ment of vertigo. Another reader wrote in to tell me that I should've mentioned that neurologists and ENT physicians often have expertise in managing cases of dizziness, if the problem can't be solved by the primary physician. Receiving the right diagnosis is essen- tial to getting the right treatment.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column when- ever possible. Readers may email ques- tions to ToYourGoodHealth @med.cornell.edu.