Is It Safe to Follow Cystic Pancreatic Neoplasms if Immediate Surgery Is Not Undertaken?

Abstract

Purpose: To characterize clinical outcomes and follow up in patients with pancreatic cystic neoplasms not undergoing surgical intervention. Methods: We searched our endoscopy database for data and included patients with pancreatic cysts between January 2005 and December 2009 with at least 12 months of clinical follow up. Inclusion criteria: Mucinous cystic neoplasms, side branch IPMN including those with Pancreatic Duct (PD) <6 mm without features of main duct IPMN, serous cystadenoma based on clinical, radiological and EUS-FNA features. Exclusion criteria: Main duct IPMN, pancreatic pseudocyst, mesenteric cysts, and pancreatic cysts that underwent surgical resection. Data on demographics, clinical presentation, CT findings at presentation and at follow up, EUS features, cyst fluid analysis, as well as clinical and radiological follow up were collected. Results: 49 patients were identified. Mean age was 68.6+/-10.9 years. 30 (61.2%) were females. Presentation included an incidental finding in 36 (73.5%), abdominal pain in 10 (20.4%) and weight loss in 3 (6.1%) patients. A solitary lesion was seen in 33 (67.3%) patients. Median size of largest cystic lesion on CT and EUS at initial presentation was 23.5 +/- 18.0 mm and 21.5 +/- 14.3 mm respectively. Locations included head in 19 (38.8%), body in 16 (32.7%), tail in 6 (12.2%), neck in 5 (10.2%), uncinate in 3 (6.1%) patients. Septae were seen in 12/49 (24.5%) patients. Other EUS findings included wall thickness in 5/49 (10.2%), intracystic component in 6/49 (12.2%), PD dilatation in 8 (16.3%) and possible cyst communication with PD in 11 (22.4%) of patients. Fluid was reportedly viscous in 17/49 (34.7%) aspirations. Mucin was seen on histopathology in 14 (28.6%) patients. Cyst CEA levels were available in 35/49 (71.4%) patients. In these 35 patients, cyst CEA level <192 ng/mL was seen in 28 (80%) and >192 ng/mL in 7 (20%) patients. A follow up CT study was available in 46/49 (93.9%) patients after a median follow up of 24.8+/-18.4 months. On follow up, cyst were seen to have regressed in size in 15 (30.6%), remained stable in size in 7 (14.3%) and increased in size in 22 (44.9%) patients. Among these 22 patients, median increase in cyst size was 5.1+/- 7.8 mm. 46/49 (93.9%) patients were alive with a median follow up of 25.5+/-15.3 months without any clinical or radiological evidence of invasive malignancy. Conclusion: Most cystic lesions of pancreas are found incidentally. It appears to be reasonably safe to follow pancreatic cysts for up to two years, including those considered to be mucinous but without overt malignancy that are not operated on for one reason or another.