The appropriate management of patients with cystic lesions of the pancreas is controversial. The identification of small asymptomatic pancreatic cysts is increasing, and the natural history of these lesions is unknown.1,2 Mucinous lesions, either intraductal papillary mucinous neoplasms (IPMN) or mucinous cystadenomas, are considered premalignant lesions; however, the time course of progression from benign to malignant has not been determined. Although serous cystadenomas are considered to be benign, local growth can result in symptoms. The growth rate of these lesions, and the size at which they become symptomatic is unknown. The present ability to determine the specific histopathology of a radiographically identified pancreatic cyst remains limited. Current laboratory, radiographic, and endoscopic studies are often able to distinguish mucinous from serous lesions, but their ability to identify malignancy within the mucinous subgroup is limited.3,4 Finally, although the mortality after pancreatectomy has decreased to less than 2% in high-volume centers, reported morbidity rates remain at approximately 40%, and reported mortality continues to be as high as 15% at lower volume hospitals.5,6

Because of the unknown natural history, and diagnostic uncertainty, some authors have recommended routine resection of all pancreatic cysts.7–9 These authors argue that because preoperative differentiation between benign and malignant is unreliable, and because the potential adverse consequences of nonresectional therapy are significant, all medically fit patients should undergo resection. Although this approach provides a guarantee to patients that no premalignant or malignant lesions will be observed, it exposes patients with benign lesions to the risks of operation with unclear benefit.

Several recent reports, including a previous study from the authors’ institution, have recommended a more selective approach to resection.10–12 This approach argues that improved radiographic imaging techniques and an improved understanding of the various histologic entities allow the identification of a group of patients with an extremely low risk of malignancy. Most studies reporting selective management have recommended nonoperative management (radiographic follow-up) for patients with small, incidentally discovered cysts of the pancreas.10–12 This approach avoids the risks of operation in patients with benign lesions, but with current limitations in nonresectional diagnosis, cannot guarantee that a malignancy is not mistakenly being observed.

This study was performed to further describe and review our selective approach to resection for patients with cystic lesions of the pancreas. The authors previously reported on a series of 209 patients.12 In that study, we identified the presence of a solid component, the cyst diameter, the presence of septations, and the presence of symptoms as factors associated with the decision to perform operative resection. The current data allow further assessment of these factors, and the ability to investigate the factors involved in the decision making process.

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A selective approach to the resection of cystic lesions of the pancreas: results from 539 consecutive patients.

Cystic lesions of the pancreas. A diagnostic and management dilemma.

OBJECTIVE. The objective of our study was to determine the role and relative accuracy of CT and MRI in the characterization of cystic pancreatic masses.MATERIALS AND METHODS. We retrospectively identified 58 patients with histopathologically proven cystic pancreatic masses at our institution who underwent preoperative CT (n =40), MRI (n = 6), or both (n = 12). Two radiologists independently recorded their leading diagnoses with levels of diagnostic certainty (0–100%), their estimates of overall likelihood of malignancy (0–100%), and the morphologic characteristics of the tumors. Data were analyzed to determine relative accuracy in the diagnosis of malignancy, relationship between diagnostic certainty and accuracy, and frequency of malignancy in unilocular thin-walled cysts smaller than 4 cm.RESULTS. Twenty-one (36%) of 58 masses were malignant. CT and MRI were equally accurate in establishing the diagnosis of malignancy (area under the receiver operating characteristic curve [Az] = 0.91 and 0.85 for revie...

Characterization of cystic pancreatic masses: relative accuracy of CT and MRI.

ObjectivesTo evaluate the performance characteristics of endoscopic ultrasonography (EUS) compared with computed tomography (CT) and magnetic resonance imaging (MRI) and determine the incremental diagnostic yield and accuracy of EUS with or without fine needle aspiration (FNA) over CT and MRI for pr

https://www.giejournal.org/article/S0016-5107(11)00902-3/pdf

Should we do EUS/FNA on patients with pancreatic cysts? the incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms

Cystic lesions of the pancreas: Selection criteria for operative and nonoperative management in 209 patients

Cystic neoplasms of the pancreas are rare, accounting for less than 1% of all pancreatic tumors Since the advent of computerized tomography (CT), an increasing number of these lesions are being discovered incidentally. Compagno and Oertel were the first to thoroughly describe and differentiate the benign serous cystadenoma from the potentially or overtly malignant mucinous cystadenoma/cystadenocarcinoma spectrum. At present, our ability to definitively differentiate between these two classes of cystic neoplasms is limited. Because of this, controversy exists as to their appropriate surgical management. A case report is presented and followed by a review of the literature on incidentally detected cystic neoplasms of the pancreas.

Sackier Jm

Papers

Incidental detection of cystic neoplasms of the pancreas