Risk of Malignancy in Resected Cystic Tumors of the Pancreas ≤3 cm in Size: Is it Safe to Observe Asymptomatic Patients? A Multi-institutional Report

Abstract

Recent international consensus guidelines propose that cystic pancreatic tumors less than 3 cm in size in asymptomatic patients with no radiographic features concerning for malignancy are safe to observe; however, there is little published data to support this recommendation. The purpose of this study was to determine the prevalence of malignancy in this group of patients using pancreatic resection databases from five high-volume pancreatic centers to assess the appropriateness of these guidelines. All pancreatic resections performed for cystic neoplasms < or =3 cm in size were evaluated over the time period of 1998-2006. One hundred sixty-six cases were identified, and the clinical, radiographic, and pathological data were reviewed. The correlation with age, gender, and symptoms (abdominal pain, nausea and vomiting, jaundice, presence of pancreatitis, unexplained weight loss, and anorexia), radiographic features suggestive of malignancy by either computed tomography, magnetic resonance imaging, or endoscopic ultrasound (presence of solid component, lymphadenopathy, or dilated main pancreatic duct or common bile duct), and the presence of malignancy was assessed using univariate and multivariate analysis. Among the 166 pancreatic resections for cystic pancreatic tumors < or =3 cm, 135 cases were benign [38 serous cystadenomas, 35 mucinous cystic neoplasms, 60 intraductal papillary mucinous neoplasms (IPMN), 1 cystic papillary tumor, and 1 cystic islet cell tumor], whereas 31 cases were malignant (14 mucinous cystic adenocarcinomas and 13 invasive carcinomas and 4 in situ carcinomas arising in the setting of IPMN). A greater incidence of cystic neoplasms was seen in female patients (99/166, 60%). Gender was a predictor of malignant pathology, with male patients having a higher incidence of malignancy (19/67, 28%) compared to female patients (12/99, 12%; p < 0.02). Older age was associated with malignancy (mean age 67 years in patients with malignant disease vs 62 years in patients with benign lesions (p < 0.05). A majority of the patients with malignancy were symptomatic (28/31, 90%). Symptoms that correlated with malignancy included jaundice (p < 0.001), weight loss (p < 0.003), and anorexia (p < 0.05). Radiographic features that correlated with malignancy were presence of a solid component (p < 0.0001), main pancreatic duct dilation (p = 0.002), common bile duct dilation (p < 0.001), and lymphadenopathy (p < 0.002). Twenty-seven of 31(87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy. Forty-five patients (27%) were identified as having asymptomatic cystic neoplasms. All but three (6.6%) of the patients in this group had benign disease. Of the patients that had no symptoms and no radiographic features, 1 out of 30 (3.3%) had malignancy (carcinoma in situ arising in a side branch IPMN). Malignancy in cystic neoplasms < or =3 cm in size was associated with older age, male gender, presence of symptoms (jaundice, weight loss, and anorexia), and presence of concerning...

Pancreatic mucinous cystoadenomas and cystoadenocarcinomas: differential diagnosis by means of MRI

“…[7][8][9][10] For benign MCNs ,3 cm in size and without mural nodules, clinical radiological follow-up has been suggested. 8,[17][18][19] Nowadays, there are only a few published studies to distinguish benign forms of MCNs from malignant forms of MCNs based on CT. 9,20 Furthermore, in a recently published study, Theruvath et al 21 proved the lower effectiveness of CT compared with MRI in predicting the diagnosis of MCNs, but at present there are no published studies based on MRI to distinguish benign forms of MCNs from malignant forms of MCNs.…”

Pancreatic cystic lesions: classification, diagnosis and treatment

“…This same study showed that most patients with malignant disease symptomatic (28/31 was-90%), with a large association with malignancy and symptoms of jaundice, weight loss and anorexia. 14 The pseudocysts may arise after an episode of acute or chronic pancreatitis. 1,15 Pseudocysts may have abdominal pain, nausea, vomiting, early satiety, jaundice, cholangitis and when the head of the pancreas, as well as thrombosis of the splenic vein, superior mesenteric or door, resulting in venous congestion and gastrointestinal bleeding.…”

Management of cystic diseases of the pancreas

“…CT findings are helpful in the evaluation of complex cystic structures. In asymptomatic patients with pancreatic cysts smaller than 3 cm, the frequency of occult malignancy was found 3.3%, whereas 90% of patients with malignant lesions were symptomatic (54). Recently IPMN was considered as a diffuse pancreatic pre-malign or malign condition, because the risk of concurrent PanIN and another IPMN are increased (21% to 41%) in these subjects (55)(56)(57)(58)(59).…”