Periampullary and pancreatic incidentaloma: a single institution's experience with an increasingly common diagnosis

Abstract

Background: While incidental masses in certain organs have received particular attention, periampullary and pancreatic incidentalomas (PIs) remain poorly characterized.

Methods: We reviewed 1944 consecutive pancreaticoduodenectomies (PD) over an 8-year period (April 1997 to October 2005). A total of 118 patients (6% of all PDs) presented with an incidental finding of a periampullary or pancreatic mass. The PI patients were analyzed and compared with the rest of the cohort (NI, nonincidentaloma group, n = 1826).

Results: Thirty-one percent of the PI patients (n = 37) had malignant disease (versus 76% of the NI patients, P < 0.001), 47% (n = 55) had premalignant disease, and the remaining 22% (n = 26) had little or no risk for malignant progression. The 3 most common diagnoses in the PI group were IPMN without invasive cancer (30%), cystadenoma (17%), and pancreatic ductal adenocarcinoma (10%). The PI group had a higher overall complication rate (55% versus 43%, P = 0.02), due in part to a significantly increased rate of pancreatic fistulas (18.4% PI versus 8.5% NI, P < 0.001). Patients in the PI group with malignant disease had a superior long-term survival (median, 30 months, P = 0.01) compared with patients in the NI group with malignant disease (median, 21 months).

Conclusions: Incidentally discovered periampullary and pancreatic masses comprise a substantial proportion of patients undergoing PD. Roughly three fourths of these lesions are malignant or premalignant, and amenable to curative resection. Resected malignant PIs have favorable pathologic features as compared with resected malignant NIs, and resection of these early lesions in asymptomatic individuals is associated with improved survival, compared with patients with symptomatic disease.

FIGURE 1. Kaplan-Meier survival curves for patients who underwent a PD for a PI, as compared with patients who presented with symptoms (NI). The 1-, 2-, and 5-year survival rates for patients in the PI group were 95%, 88%, and 68%, respectively (median, 82 months, P < 0.001). The 1-, 2-, and 5-year survival rates for patients in the NI group were 76%, 57%, and 36%, respectively (median, 33 months). PI, periampullary or pancreatic incidentaloma; NI, nonincidentaloma.

FIGURE 2. Kaplan-Meier survival curves for patients who underwent a PD for an invasive cancer (in situ lesions are excluded) in the PI group, as compared with patients who presented with symptoms (NI). The 1-, 2-, and 5-year survival rates for patients in the PI group were 93%, 70%, and 50%, respectively (median, 30 months, P = 0.01). The 1-, 2-, and 5-year survival rates for patients in the NI group were 70%, 46%, and 23%, respectively (median, 21 months). PI, periampullary or pancreatic incidentaloma; NI, nonincidentaloma.

FIGURE 3. Kaplan-Meier survival curves for patients who underwent a PD for ductal adenocarcinoma of the pancreas in the PI group, as compared with the patients who presented with symptoms (NI). The 1-, 2-, and 5-year survival rates for patients in the PI group were 100%, 62%, and 50%, respectively (median, 28 months, P = 0.04). The 1-, 2-, and 5-year survival rates for patients in the NI group were 64%, 38%, and 14%, respectively (median, 18 months). PI, periampullary or pancreatic incidentaloma; NI, nonincidentaloma.