Dedicated Multidisciplinary Team And Adherence To International Consensus Guidelines Promotes Appropriate Resection Of Pancreatic Cystic Lesions: A Single Center Experience

The management of pancreatic cystic lesions (PCLs) is complex, with evolving guidelines over time. We sought to compare appropriateness of surgeries based on operative pathology before and after implementation of International Consensus Guidelines (ICG; 2012), dedicated multidisciplinary pancreas team, and novel diagnostic modalities. Consecutive subjects who underwent EUS-fine needle aspiration prior to resection of PCL were enrolled in the study. The study time periods included the “current time period” (July 2014 to November 2017, 40 months) and “prior time period” (January 2009 to April 2013, 40 months). Diagnoses based on surgical histopathology. Subjects were excluded if there was evidence of metastatic disease on imaging study, main duct intraductal papillary mucinous neoplasm (MD-IPMN), surgery performed for chronic or acute pancreatitis, solid pancreatic lesions, and cyst size <1.5 cm. We collected demographic and clinical features, PCL morphology on imaging and EUS, cyst fluid analysis, details of surgical histopathology, high and worrisome risk features (ICG 2012), and indication for resection. A total of 107 subjects met the inclusion criteria for study. 55 subjects (mean age 59.2±13.2; 62% female) underwent pancreatic resections in the prior time-period and 52 subjects (mean age 62.0 ± 13.0; 50% female) in the current time-period. PCLs with a larger cyst size were resected in the current time-period compared to the prior era (4.1 ± 2.1 cm vs. 3.2 ± 2.0 cm; p = 0.03). Previously, a higher proportion of subjects with high CEA and suspicious cytology in the absence of worrisome/high risk ICG features (25 vs. 0) were resected (Table 1), while in the current-time period the majority of the PCLs had at least one worrisome criteria present (65.4% vs. 23.6%, p <0.01). In the prior time-period, a higher proportion of resected IMPNs had low-grade dysplasia (31% vs. 17.4%, p = 0.05), while in the current time-period the majority of the cysts resected had high-grade dysplasia (65.4% vs. 15.0%, p = 0.03). A dedicated multidisciplinary team guided by ICG guidelines and novel diagnostic modalities improves the proportion of patients undergoing appropriate resection for PCLs at a single tertiary care center.Tabled 1Table 1. Demographics, clinical features, and histopathology of patients who underwent resection of pancreatic cystic lesionsVariablePrior-time period%Current-time period%p-valueN: 55N: 52Clinical featuresCyst size (cm), mean (SD)3.2 ± (2.03)4.1 ± (2.01)0.03Age (years), mean (SD)59.2 ± (13.2)61.0 ± (13.0)0.05Female34622650<0.01CEA ≥ 192*2054.12252.41.0Reason for surgeryHigh risk ICG 2012712.714270.09Worrisome ICG 20121323.63465.4<0.01High CEA in absence of high risk/worrisome criteria712.7--Patient decision/symptomatic814.647.60.36Abnormal or suspicious cytology in absence of high risk/worrisome criteria1832.7--DiagnosisOther benign cyst**23.659.60.26Pseudocyst35.535.81.0Cystic NET814.559.60.56IPMN-BD/Mix2545.52446.21.0MCN1120815.40.62Serous Cystadenoma59.123.80.44Other Cancer11.859.60.11Dysplasia Degree, IPMNLow-grade Dysplasia1731917.40.05High-grade Dysplasia/Adenocarcinoma8153465.40.03Total IMPN254524461.0 Open table in a new tab