Cystic pancreatic lesions – do we need radical surgery?

Introduction: Despite improved diagnostic methods, correct diagnosis and treatment of cystic lesions of the pancreas (CLP) still constitutes a clinical challenge. This study aimed at retrospective evaluation of diagnostic accuracy and surgical treatment of CLP.

Methods: Patients with CLP referred to our institution for evaluation and treatment between 2001 and 2012 were retrospectively analyzed. Statistical calculations were performed with IBM SPSS Version 20.

Results: A total of n = 234 patients of median age 63 (range 22 – 90) years were included in the study, of whom n = 160 (68%) were operated, n = 17 treated minimally invasive or interventionally and n = 57 were observed only. Most frequent definite histologically confirmed lesions in the 160 operated patients were benign pancreatic pseudocysts (BPP, 30%) and intraductal papillary mucinous neoplasms (IPMN, 24%), followed by various rare entities like serous and mucinous cystic neoplasms, cystadenocarcinoma, neuroendocrine tumor and others. Of resected IPMN, 46% were invasive and multivariate analysis disclosed younger age, absence of symptoms or former malignancy and presence of diabetes as independent risk factors for invasive transformation.

Clinical or preoperative classification as benign or malignant showed fair accuracy, as only 4% of lesions regarded as benign turned out to be malignant after resection and no patient without resection developed malignancy at a median follow-up of 8 months. In the subgroup of patients operated for suspected benign IPMN, malignancy rate was 13%.

Conclusions: Preoperative diagnostic accuracy regarding benign or malignant biology for CLP is relatively high. We suggest that limited parenchyma-sparing techniques with intraoperative frozen section evaluation can be performed if benign CLP are suspected. The finding that younger age and absence of symptoms were risk factors for invasive IPMN needs further validation.