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The Incidental Asymptomatic Pancreatic Lesion: Nuisance or Threat?

Teviah Sachs, MD, Wande B. Pratt, MD, MPH, Mark P. Callery, MD, Charles M. Vollmer, Jr, MD
Beth Israel Deaconess Medical Center; Boston, MA




PURPOSE OF STUDY:
Asymptomatic pancreatic lesions (APLs) are being discovered incidentally with increasing frequency and treatment decisions pivot off concerns for malignancy.

METHODS USED:
Incidentally identified APLs operated upon during the past 5 years were reviewed as were all referred APLs over last 2 years since Sendai Guideline adoption.

SUMMARY OF RESULTS:
Over 5 years, APLs were identified most frequently during evaluation of: GU/Renal (16%), Asymptomatic rise in LFTs (13%), Screening/Surveillance (7%), and Chest Pain (6%). APLs occurred in the body/tail-63% & head/uncinate-37%, with 48% being solid. 110 operations were performed with the 89 resections (Distal-57; Whipple- 32) accounting for 23% of all our pancreatic resections. 22 different diagnoses emerged including IPMN(17%), serous cystadenoma(14%), and neuroendocrine tumors(13%). The overall malignancy rate was 24%; These patients were older (68 vs 58 yrs; p=0.003). Asymptomatic rise in LFTs correlated with malignancy (p=0.009). Seven patients ultimately converted to operation over continued observation (mean 2.6 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 1/2 were operated upon, with a 3:2 ratio of solid to cystic lesions. This differs significantly (p=0.037) from the previous 3 years (2:3 ratio). Surgery was undertaken more often for solid APLs (74%) than for cysts (32%) with some being unresectable cancers.

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.

 

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