Current trends in pancreatic cystic neoplasms

Abstract

Objective: To define how patients with pancreatic cysts are being diagnosed and treated.

Design: Retrospective case series.

Setting: University-affiliated tertiary care center.

Patients: Four hundred one patients evaluated in the Department of Surgery between January 2004 and December 2007.

Main outcome measures: Clinical management, histological diagnosis, and results of surveillance.

Results: Pancreatic cysts were incidentally discovered in 71% (284 of 401) of patients. There was no statistically significant difference in age (60.4 vs 63.1 years; P = .10), cyst size (31 vs 27 mm; P = .12), or histological diagnosis between symptomatic patients and patients with incidentally discovered cysts. Whereas the majority of symptomatic patients had their cystic neoplasms resected on diagnosis, 50% (142 of 284) of incidentally discovered cysts were initially managed nonoperatively. Of the patients who were managed with surveillance, 13 (8%) subsequently underwent resection after a median of 2.1 years because of an increase in cyst size, development of symptoms, increasing tumor markers, worrisome endoscopic ultrasonography findings, or patient anxiety. The most common diagnosis among resected lesions was either main-duct intraductal papillary mucinous neoplasm (25%) or branch-duct intraductal papillary mucinous neoplasm (23%). Invasive cancer was found in 29 of 256 (11%) resected cystic neoplasms, 9 of which were incidentally discovered, and in 7% (1 of 13) of patients who underwent watchful waiting prior to resection.

Conclusions: Incidentally discovered pancreatic cystic neoplasms composed 71% of our series, of which 50% were immediately resected. Subsequent morphologic changes or development of symptoms prompted an operation in 8% of patients after a period of surveillance. Invasive malignancy was present in 11% of all resected specimens but in 38% of main-duct intraductal papillary mucinous neoplasms.

Figure

Fluid carcinoembryonic antigen (CEA) and amylase concentrations in resected cystic lesions of the pancreas. A, Carcinoembryonic antigen level in the fluid aspirated from 79 resected cystic lesions of the pancreas. IPMN indicates intraductal papillary mucinous neoplasm; MCN, mucinous cystic neoplasm; and SCA, serous cystadenoma. “Other” includes benign uncharacterized cysts (4), cystic neuroendocrine tumors (3), solid pseudopapillary tumor (2), ductal adenocarcinoma (2), enteric duplication cysts (2), cystic acinar cell carcinoma (1), acinar cell cystadenoma (1), and lymphangioma (1). To convert CEA to micrograms per liter, multiply by 1. B, Amylase concentration in the fluid aspirated from 66 resected cystic lesions of the pancreas. “Other” includes cystic neuroendocrine tumors (3), ductal adenocarcinoma (2), enteric duplication cysts (2), benign uncharacterized cysts (1), solid pseudopapillary tumor (2), cystic acinar cell carcinoma (1), retention cyst (1), and lymphangioma (1). To convert amylase to microkatals per liter, multiply by 0.0167.