Pancreatectomy for pancreatic incidentaloma: What are the risks?

Abstract

Background

Pancreatic incidentalomas (PI) are nowadays common but the benefit-risk balance of surgery remains difficult to determine.

Methods

Monocentric retrospective study of 881 pancreatectomies comparing resected PI with symptomatic lesion. Univariate and multivariate (MV) analyses were done to identify risk factors of malignancy in PI undergoing surgery.

Results

Overall, 32% of pancreatectomies were performed for PI. Median size of PI was 30 mm (vs 28 mm; p = 0.15) and 49% were cystic (vs 42%; p = 0.197). Resected PI were mostly located in distal pancreas (61% vs 34%; p < 0.001), less frequently malignant (49% vs 59%; p = 0.004). PNETs were more frequent in PI (50% vs 21%; p < 0.001). Distal pancreatectomy (36% vs 23%; p < 0.001) or parenchyma-sparing surgery (34% vs 13%; p < 0.001) were more frequently performed for PI. Overall mortality (1.1% vs 1.2%) and morbidity (70% vs 68%) were not significantly different between both groups. Severe morbidity was lower for PI (15% vs 22%; p = 0.007). In multivariate analysis, age>55 years (HR 6.14; p < 0.001), size >20 mm (HR:26.7; p < 0.001) and biliary dilatation (HR 29.9; p = 0.027) were independent risk factors of malignancy and, when associated, the likelihood of malignancy was above 90%.

Conclusions

PI represent about 30% of indications for pancreatectomy and when resected after careful selection are malignant in 50% of cases.

Introduction

With the widespread use of high-quality cross-sectional imaging, an increased number of asymptomatic solid or more frequently cystic pancreatic lesions are being identified. The prevalence of these so called “incidentalomas”, i.e. asymptomatic mass fortuitously detected by imaging, is approximately 10% [1] in the population and may reach as high as 30% in patients over 70 years of age [2]. Pancreatic incidentaloma encompasses a wide spectrum of neoplasms, including serous cystadenomas (SCA), mucinous cystic neoplasms (MCN), mucinous cystadenocarcinomas, non-functional neuroendocrine tumors (PNET), solid and pseudopapillary neoplasm (SPPN) and intraductal papillary mucinous neoplasms (IPMN) [3]. The main issue in their management is that beyond their comforting presentation, this heterogeneous group of lesions can be premalignant or even malignant.

This concern has led to an increasing number of resections for pancreatic incidentaloma in order to eradicate potentially threatening pancreatic lesions in their earliest stages. However, the mortality of pancreatic surgery ranges from 1% to 3% in high-volume centers [4], [5], but increases up to 6–10% when nationwide data are considered [6], [7], [8]. Consequently, surgical indication must be carefully weighted in asymptomatic patients.

The aim of the present study is to describe patients with pancreatic incidentaloma selected for surgery from a large database of pancreatectomies performed at a single institution, to compare them with symptomatic patients, and to determine risk factors of malignancy.