2008 Annual Meeting Abstracts

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Introduction: Although asymptomatic pancreatic lesions (APLs) are being discovered incidentally with increasing frequency, their true significance remains obscure. Treatment decisions pivot off concerns for malignancy, but at times might be excessive. To better understand the role of surgery, we scrutinized a spectrum of APLs as they presented to our surgical practice over defined periods.
Methods: All incidentally identified APLs that were operated upon during the past 5 years were clinically and pathologically annotated. Among features evaluated were method/reason for detection, location, morphology, interventions and pathology. For the past 2 years, since our adoption of the Sendai guidelines for cystic lesions, we scrutinized our approach to all patients presenting with APLs, operated upon or not.
Results: Over 5 yrs, APLs were identified during evaluation of: GU/Renal (14%), Asymptomatic rise in LFTs (13%), Screening/Surveillance (7%) and Chest Pain (6%). APLs occurred throughout the pancreas (body/tail-63%; head/UP-37%) with 51% being solid. 110 operations were performed with no operative mortality including 89 resections (Distal-57; Whipple- 32) and 21 other procedures. During these 5 years, APLs accounted for 27% of all pancreatic resections we performed. In all, 21 different diagnoses emerged including IPMN (19%), serous cystadenoma (13%), and neuroendocrine tumors (13%), while 8% of pts had >1 distinct pathology and 12% had no actual pancreatic lesion at all. Invasive malignancy was present 17% of the time and these pts were older (67.3 to 60.9 yrs; p<.05). Adenocarcinoma predominated (16%). An asymptomatic rise in LFTs correlated significantly (p<.01) with malignancy. Seven pts ultimately opted for operation over continued observation (mean 2.7 yrs), but none had cancer. In the last 2 years, we have evaluated 132 new patients with APLs, representing 47% of total referrals for pancreatic conditions. Nearly half were operated upon, with a 3:2 ratio of solid to cystic lesions. This differs significantly (p<.05) from the previous 3 years (2:3 ratio), reflecting tolerance for cysts <3 cm and side-branch IPMN. Surgery was undertaken more often for solid APLs (74%) than cysts (32%). Some solid APLs were actually unresectable cancers. Due to anxiety, 2 pts requested operation over continued observation, and neither had cancer.
Conclusions: APLs occur commonly, are often solid and reflect a spectrum of diagnoses. Sendai guidelines are not transferable to solid masses, but have safely refined management of cysts. An asymptomatic rise in LFTs cannot be overlooked, nor should a patient or doctor’s anxiety, given the prevalence of cancer in APLs.

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