Elsevier

Surgery

Volume 144, Issue 4, October 2008, Pages 677-685
Surgery

Central Surgical Association
Management of suspected pancreatic cystic neoplasms based on cyst size

https://doi.org/10.1016/j.surg.2008.06.013Get rights and content

Background

Evaluation and management of cystic pancreatic neoplasms remain problematic. International consensus guidelines have advised resection for lesions greater than 3 cm.

Methods

We reviewed our prospective pancreatic cystic neoplasm database for outcomes based on a cyst size of 3 cm.

Results

Five hundred patients have been managed from 1999 to 2006. There were 349 patients (70%) with cysts less than or equal to 3 cm: 293 (84%) were not operated, including 243 nonmucinous cysts: 2 failed observation (0.8%, mean follow-up of 24 months). Fifty-six patients with cysts less than or equal to 3 cm were initially operated (16%), including 23 asymptomatic patients. Histopathology showed intraductal papillary mucinous neoplasm (IPMN) in 20, mucinous cystic neoplasm (MCN) in 18, and serous cystadenoma in 5. Twelve had carcinoma (21%). A total of 151 patients (30%) had cysts greater than cm: 87 (50%) were not operated, including 68 that were nonmucinous: 2 failed observation (2.9%, mean follow-up of 47 months). Sixty-four patients with cysts greater than 3 cm (42%) were initially operated, and final pathology showed MCN in 27, serous cystadenoma in 11, IPMN in 7, and pseudocyst in 7. Twelve had carcinoma (19%). Patients with cysts less than or equal to 3 cm were less likely to be operated (16 vs 42%; P < .001), less often symptomatic (39 vs 50%; P = .017), while older (mean age, 65 vs 61 years; P = .03). Had patients been managed by size alone, up to 20% would have received inappropriate treatment. Management based on aspiration was significantly better in predicting mucinous neoplasms compared with size (75% vs 57%; P < .001), including asymptomatic patients less than or equal to 3 cm (78% vs 65%; P = .003).

Conclusion

Size of pancreatic cystic lesions alone is not a reasonable basis for determining management.

Section snippets

Patients and methods

An institutional review board–approved, prospective evaluation and management protocol was initiated in September 1999 for adults with suspected pancreatic cystic neoplasm observed in the Digestive Disease Institute at the Cleveland Clinic. Patients are managed independent of cyst size, and patients are advised to undergo resection based on defined criteria: the presence of symptoms, abnormal cyst aspiration fluid, and radiologic criteria. Symptoms included abdominal pain, jaundice,

Results

A total of 500 patients have been managed from September 1999 through December 2006, with the Figure outlining the overall results of management. The entire group included 326 women and 174 men with a mean age of 64 (22 to 93) years. A total of 125 patients (25%) were operated principally for symptoms and/or aspiration results. Compared with patients not operated, patients that underwent operation were significantly more likely to be symptomatic (64 vs 35%; P < .001) and younger (58 vs 66 mean

Discussion

A need exists for increased outcomes data for patients with suspected pancreatic cystic neoplasms. The need is pressing, but there are conflicting concerns: the number of patients at risk is large because of expanded use of cross-sectional imaging, pancreatic surgery is an increasingly safe procedure at major centers, plus high patient and physician anxiety about a delay in diagnosis of pancreatic carcinoma. Little true guidance can be found in most of the surgical literature because most

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