Preoperative classification of pancreatic cystic neoplasms: the clinical significance of diagnostic inaccuracy

Abstract

Background: The potential for malignant transformation varies among pancreatic cystic neoplasms (PCN) subtypes. Imaging and cyst fluid analysis are used to identify premalignant or malignant cases that should undergo operative resection, but the accuracy of operative decision-making process is unclear. The objective of this study was to characterize misdiagnoses of PCN and determine how often operations are undertaken for benign, non-premalignant disease.

Methods: A retrospective analysis of patients undergoing pancreatic resection for the preoperative diagnosis of PCN was undertaken. Preoperative and pathological diagnoses were compared to measure diagnostic accuracy.

Results: Between 1999 and 2011, 74 patients underwent pancreatic resection for the preoperative diagnosis of PCN. Preoperative classification of mucinous vs. non-mucinous PCN was correct in 74%. The specific preoperative PCN diagnosis was correct in 47%, but half of incorrect preoperative diagnoses were clinically equivalent to the pathological diagnoses. The likelihood that the pathological diagnosis was of higher malignant potential than the preoperative diagnosis was 7%. In 20% of cases, the preoperative diagnosis was premalignant or malignant, but the pathological diagnosis was benign. Diagnostic accuracy and the rate of undercall diagnoses and overcall operations did not change with the use of EUS or during the time period of this analysis.

Conclusions: Precise, preoperative classification of PCN is frequently incorrect but results in appropriate clinical decision-making in three-quarters of cases. However, one in five pancreatic resections performed for PCN was for benign disease with no malignant potential. An appreciation for the rate of diagnostic inaccuracies should inform our operative management of PCN.

FIG. 1

a Breakdown of preoperative PCN diagnoses. b Breakdown of pathological PCN diagnoses. SC serous cystadenoma, MC mucinous cystic neoplasm, IPMN-B branch duct intraductal papillary mucinous neoplasm, IPMN-M main duct or mixed type intraductal papillary mucinous neoplasm, NE cystic neuroendocrine neoplasm, CA mucinous cystadenocarcinoma, IND indeterminate, SP solid pseudopapillary neoplasm, PC pseudocyst, LC lymphoepithelial cyst

FIG. 2

a Distributions of pathological diagnoses for selected preoperative diagnoses. b Distributions of pathological diagnoses for preoperative classification of non-mucinous versus mucinous PCN

FIG. 3

Breakdown of diagnostic errors. Undercall diagnosis case in which the pathological diagnosis was of higher malignant potential than the preoperative diagnosis, overall operation case in which the preoperative diagnosis was either premalignant or malignant and the pathological diagnosis was benign