DOI: 10.1097/01.sla.0000261156.83438.23
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Issn Print: 0003-4932
Publication Date: 2007/05/01
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Excerpt
These statements alone are a dramatic departure from what was typically published just a decade ago, when most reports recommended resection for all patients with cystic lesions of the pancreas.1–3 Recent improvements in cross-sectional imaging, the resultant increase in identification of small asymptomatic cysts (often between 4 mm and 2 cm in diameter), and the improving ability to determine histologic subtype without resection make the former approach impractical and potentially harmful to the patient. After a thorough diagnostic evaluation, treatment recommendations should be made that are based on the balance between the risk of malignancy within the given lesion and the risk of pancreatectomy to the individual patient. For patients with presumed mucinous tumors, this balance must also include the possible risk of developing malignancy in the future.
We agree with some of Dr. Crippa's concern regarding the terminology used to describe these lesions; and with improvements in diagnosis we hope to approach these lesions with histopathologic terminology (serous, mucinous, malignant IPMNs) rather than radiologic terminology (cystic lesion). We do approach main-duct IPMNs differently than branch-duct IPMNs, and Dr Crippa's statement that we “assume that main-duct IPMNs are unlikely to present as a cystic lesion of the pancreas” is a misunderstanding of statements within the discussion of the paper and should be clarified. This is a denominator issue and one that was touched upon in the discussion by Dr Lillemoe. Patients were included in this study (as noted in METHODS) if they were coded for the ICD-9 diagnosis of pancreatic cyst (577.2), had a cystic lesion of the pancreas on imaging, and were evaluated by a surgeon or gastroenterologist. We thought that these criteria best defined the group of patients with the radiographic finding of a “cystic lesion of the pancreas.” Most patients with main-duct IPMNs will have malignancy, and these patients were typically coded with the ICD-9 code 157.9 (pancreatic adenocarcinoma). This would be similar in a patient with an obvious pancreatic adenocarcinoma that had cystic degeneration: they would not typically be coded as a pancreatic cyst but rather as an adenocarcinoma. Patients with a cystic tumor that was biopsy-proven as an adenocarcinoma were also not included. Including these patients would have changed the overall denominator but would not have changed the number of patients initially followed radiographically. Yes, main-duct IPMNs are “cystic” but these lesions have a high-rate of malignancy and should be approached in that fashion.
Where do we disagree? We disagree with Dr. Crippa's conclusion in point 2. The 8 patients with adenocarcinoma who were initially followed radiographically could have had a malignant mucinous tumor that slowly progressed, but most likely did not. In only 3 of the 8 patients was the period between the identification of the cyst and the diagnosis of carcinoma >48 months, and in these patients it is unclear whether there was an association between the cyst and the subsequent malignancy. In addition, pathology reports from the 3 resected patients (including the patient presented in Fig.
