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What Is the Diagnostic Accuracy of Preoperative Assessement Prior to Pancreatoduodenectomy in the 21st Century?
Daniel Joyce*1, Omar a. Sirsy2, Chevonne Brady1, Gavin a. Falk3, Gareth Morris-Stiff1, R Matthew Walsh1
1Cleveland Clinic Foundation, Cleveland, OH; 2Royal College of Surgeons in Ireland, Dublin, Ireland; 3Miami Children's Hospital, Miami, FL
Introduction: Malignant masquerade describes the scenario in which an operation is performed for what is presumed to be a malignant condition but for which final histopathology is benign. The aim of this study was to investigate the incidence and importance of masquerade in a contemporary pancreatoduodenectomy (PD) series.
Methods: Under IRB approval, a retrospective review of a prospectively collected database of patients at a tertiary care institution who underwent PD from 2000 to 2014 was performed. Final histopathology was compared to the final pre-operative diagnosis. The investigatory pathways of these patients were then evaluated.
Results: 894 patients underwent PD during the study period and 61 had a benign final histopathology when a malignant origin was presumed. 56 (92%) had a biopsy or cytology performed with 15 showing atypia and an additional 9 suggestive of carcinoma. 24 patients had pre-malignant pathologies (IPMN, Duodenal & ampullary adenomas), and 15 with head pancreatic masses had a final diagnosis of chronic pancreatitis. The remaining 22 patients had a variety of conditions with no malignant potential. 17 of the 22 were symptomatic, the commonest being jaundice [n=13]. Suspicious radiology was present in all cases with a mass [n=16] and/or stricture [n=13], and 8 had concerning cytology. All patients with incidental lesions had endoscopic evaluation with cytological assessment. There was a single post-operative mortality.
Conclusion: Despite modern imaging and endoscopic ultrasound, some patients still undergo resection for benign conditions without malignant potential. However for these patients PD is an acceptable approach when concern for malignancy remains despite thorough evaluation.
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