Increased Incidence of Benign Pancreatic Pathology following Pancreaticoduodenectomy for Presumed Malignancy over 10 Years despite Increased Use of Endoscopic Ultrasound
Despite using imaging studies, tissue sampling, and serologic tests about 5–10% of surgeries done for presumed pancreatic malignancies will have benign findings on final pathology. Endoscopic ultrasound (EUS) is used with increasing frequency to study pancreatic masses. The aim of this study is to examine the effect of EUS on prevalence of benign diseases undergoing Whipple over the last decade. Patients who underwent Whipple procedure for presumed malignancy at Emory University Hospital from 1998 to 2011 were selected. Demographic data, history of smoking and drinking, history of diabetes and pancreatitis, imaging data, pathology reports, and tumor markers were extracted. 878 patients were found. 95 (10.82%) patients had benign disease. Prevalence of benign finding had increased over the recent years despite using more EUS. Logistic regression models showed that abdominal pain (OR: 5.829, 95% CI 2.681–12.674, ≤ 0.001) and alcohol abuse (OR: 3.221, CI 95%: 1.362–7.261, : 0.002) were predictors of benign diseases. Jaundice (OR: 0.221, 95% CI: 0.084–0.58, : 0.002), mass (OR: 0.145, 95% CI: 0.043–0.485, : 0.008), and ductal dilation (OR: 0.297, 95% CI 0.134–0.657, : 0.003) were associated with malignancy. Use of imaging studies, ERCP, and EUS has not decreased the percentage of benign findings after surgery for presumed pancreatic malignancy. 1. Introduction Pancreatic cancer accounts for 2% of newly diagnosed malignancies, with pancreaticoduodenectomy (The Whipple procedure) being the only potentially curative treatment [1]. Differentiating between pancreatic carcinoma and benign diseases of the pancreas such as chronic pancreatitis is challenging. Pancreatic cancer can present with vague symptoms that overlap with the symptomatology of benign diseases and have an insidious course. The imaging findings also overlap between benign and malignant diseases and no single finding such as pancreatic duct dilation, focal mass, cyst, or abnormal enhancement pattern can reliably make the differentiation. In addition, secondary inflammatory changes are often seen in pancreatic cancer while chronic pancreatitis is associated with an increased risk of pancreatic carcinoma [2]. Although the outcome of the Whipple procedure has improved significantly over the past years and is associated with 1-2% mortality when performed in large volume centers, the morbidity of the procedure remains high [3]. Therefore, constant efforts are being made to improve available diagnostic tools in order to prevent performing Whipple for benign diseases. Despite the advances in imaging
References
[1]
R. H. Hawes, Q. Xiong, I. Waxman, K. J. Chang, D. B. Evans, and J. L. Abbruzzese, “A multispecialty approach to the diagnosis and management of pancreatic cancer,” The American Journal of Gastroenterology, vol. 95, no. 1, pp. 17–31, 2000.
[2]
A. B. Lowenfels, P. Maisonneuvi, G. Cavallini et al., “Pancreatitis and the risk of pancreatic cancer,” The New England Journal of Medicine, vol. 328, no. 20, pp. 1433–1437, 1993.
[3]
J. L. Cameron, T. S. Riall, J. Coleman, and K. A. Belcher, “One thousand consecutive pancreaticoduodenectomies,” Annals of Surgery, vol. 244, no. 1, pp. 10–15, 2006.
[4]
S. C. Abraham, R. E. Wilentz, C. J. Yeo et al., “Pancreaticoduodenectomy (Whipple resections) in patients without malignancy: are they all “chronic pancreatitis”?” The American Journal of Surgical Pathology, vol. 27, no. 1, pp. 110–120, 2003.
[5]
S. A. Barnes, K. D. Lillemoe, H. S. Kaufman et al., “Pancreaticoduodenectomy for benign disease,” The American Journal of Surgery, vol. 171, no. 1, pp. 131–135, 1996.
[6]
T. M. Manzia, L. Toti, I. Lenci et al., “Benign disease and unexpected histologocal findings after pancreaticoduodenectomy: the role of endoscopic ultrasound fine needle aspiration,” Annals of the Royal College of Surgeons of England, vol. 92, no. 4, pp. 295–301, 2010.
[7]
A. R. Sasson, J. M. Gulizia, A. Galva, J. Anderson, and J. Thompson, “Pancreaticoduodenectomy for suspected malignancy: have advancements in radiographic imaging improved results?” The American Journal of Surgery, vol. 192, no. 6, pp. 888–893, 2006.
[8]
C. D. Smith, K. E. Behrns, J. A. van Heerden, and M. G. Sarr, “Radical pancreatoduodenectomy for misdiagnosed pancreatic mass,” The British Journal of Surgery, vol. 81, no. 4, pp. 585–589, 1994.
[9]
D. A. Tessler, A. Catanzaro, V. Velanovich, S. Havstad, and S. Goel, “Predictors of cancer in patients with suspected pancreatic malignancy without a tissue diagnosis,” The American Journal of Surgery, vol. 191, no. 2, pp. 191–197, 2006.
[10]
J. S. Thompson, K. M. Murayama, J. A. Edney, and L. F. Rikkers, “Pancreaticoduodenectomy for suspected but unproven malignancy,” The American Journal of Surgery, vol. 168, no. 6, pp. 571–573, 1994.
[11]
T. M. van Gulik, J. W. A. J. Reeders, A. Bosma et al., “Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer,” Gastrointestinal Endoscopy, vol. 46, no. 5, pp. 417–423, 1997.
[12]
S. M. Weber, O. Cubukcu-Dimopulo, J. A. Palesty et al., “Lymphoplasmacytic sclerosing pancreatitis: inflammatory mimic of pancreatic carcinoma,” Journal of Gastrointestinal Surgery, vol. 7, no. 1, pp. 129–139, 2003.
[13]
T. Kennedy, L. Preczewski, S. J. Stocker et al., “Incidence of benign inflammatory disease in patients undergoing Whipple procedure for clinically suspected carcinoma: a single-institution experience,” The American Journal of Surgery, vol. 191, no. 3, pp. 437–441, 2006.
[14]
M. G. House, C. J. Yeo, J. L. Cameron et al., “Predicting resectability of periampullary cancer with three-dimensional computed tomography,” Journal of Gastrointestinal Surgery, vol. 8, no. 3, pp. 280–288, 2004.
[15]
M. Patlas, W. Deitel, B. Taylor, S. Gallinger, and S. R. Wilson, “Focal chronic pancreatitis mimicking pancreatic head carcinoma: are there suggestive features on ultrasound?” Canadian Association of Radiologists Journal, vol. 58, no. 1, pp. 15–21, 2007.
[16]
S. G. de la Fuente, E. P. Ceppa, S. K. Reddy, B. M. Clary, D. S. Tyler, and T. N. Pappas, “Incidence of benign disease in patients that underwent resection for presumed pancreatic cancer diagnosed by endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA),” Journal of Gastrointestinal Surgery, vol. 14, no. 7, pp. 1139–1142, 2010.
[17]
M. J. van Heerde, K. Biermann, P. E. Zondervan et al., “Prevalence of autoimmune pancreatitis and other benign disorders in pancreatoduodenectomy for presumed malignancy of the pancreatic head,” Digestive Diseases and Sciences, vol. 57, no. 9, pp. 2458–2465, 2012.
