Pancreatic cystic lesions are incidentally detected in more than a million patients annually in the U.S. and they represent the only radiographically detectable precursor to pancreatic cancer. Although most pancreatic cysts will not develop cancer, the presence of a pancreatic cystic lesion larger than 1 cm is associated with a 10-fold increased likelihood of adenocarcinoma within 5 years (6). Most of the pancreatic cystic lesions with the potential to develop high grade dysplasia/invasive adenocarcinoma (“advanced neoplasia”, AN) are lined by epithelial cells that produce an abundance of mucin, and thus are broadly classified as mucinous, and about 75% of mucinous cystic lesions are Intraductal Papillary Mucinous Neoplasms (IPMNs). Is estimated that at least 16% of adenocarcinomas arise from IPMNS
One of the major challenges is to identify the mucinous cysts with AN for early-stage surgical resection. Patients with PCLs are typically managed by surgeons and gastroenterologists according to one of several clinical guidelines that include clinical and imaging features. In a retrospective study, we applied the consensus guidelines to 251 surgically resected branch-duct IPMNs, the positive predictive value for a “worrisome feature” was only 30%, and even at our high-volume academic institutions 50% of the patients had benign tumors removed, most unnecessarily.(8) Pancreatic resection involves major life-altering surgery, however, in the absence of accurate diagnostic testing, clinical decision- making has been driven by fear of the poor prognosis associated with late-stage diagnosis. Accurate diagnosis of pre-cancerous high-grade dysplasia or early-stage (T1) invasive IPMNs is the goal of diagnostic testing as resection of these lesions is associated with >75% 5-year survival
Surgical resection of Pancreatic Cystic Lesions
**Reasons to not resect lesions with low malignancy risk
A large majority of Pancreatic cysts are found incidentally in CT and MRIs. From these cysts a portion of them (%) may be precursors of pancreatic cancer, thus posing an imminent risk, while the vast majority of them are benign and will not develop cancer in the lifetime of the patient. Increase detection of pancreatic cysts provides an opportunity to diagnose pancreatic malignancies at an early stage where they may still be curable. However, for those lesions that will not become malignant there is the potential to over-treat clinically insignificant lesions. This present a clinical challenge to prevent unnecessary resection of cysts in surgical procedures that have risks of infections, bleeding, development of diabetes, and costly disability.