Management of suspected pancreatic cystic tic neoplasms based on cyst size

Background. Evaluation and management of cystic pancreatic neoplasms remain problematic. International consensus guidelines have advised resection for lesions greater than 3 cm. Methods. We reviewed our prospective pancreatic cystic neoplasm database for outcomes based on a cyst size of 3 cm. Results. Five hundred patients have been managed from 1999 to 2006. There were 349 patients. (70%) with cysts less than or equal to 3 cm: 293 (84%) were not operated, including 243 nonmucinous cysts: 2 failed observation (0.8%, mean follow-up of 24 months). Fifty-six patients with cysts less than or equal to 3 cm were initially operated (16%), including 23 asymptomatic patients. Histopathology showed intraductal papillary mucinous neoplasm (IPMN) in 20, mucinous cystic neoplasm (MCN) in 18, and serous cystadenoma in 5. Twelve had carcinoma (21%). A total of 151 patients (30%) had cysts greater than cm: 87(50%) were not operated, including 68 that were nonmucinous: 2 failed observation (2.9%, mean follow-up of 47 months). Sixty-four patients with cysts greater than 3 cm (42%) were initially operated, and final pathology showed MCN in 27, serous cystadenoma in 11, IPMN in 7, and pseudocyst in 7. Twelve had carcinoma (19%). Patients with cysts less than or equal to 3 cm were less likely to be operated (16 vs 42%; P < .001), less often symptomatic (39 vs 50%; P=.017), while older (mean age, 65 vs 61 years; P=.03). Had patients been managed by size alone, up to 20% would have received inappropriate treatment. Management based on aspiration was significantly better in predicting mucinous neoplasms compared with size (75% vs 57%; P<0..1), including asymptomatic patients less than or equal to 3 cm (78% vs 65%; P=.003). Conclusions. Size of pancreatic cystic lesions alone is not a reasonable basis for determining management.(Surgery 2008;144:677-85.).