Spinelli Kristine S, Fromwiller Travis E, Daniel Roger A, Kiely James M, Nakeeb Attila, Komorowski Richard A, Wilson Stuart D, Pitt Henry A
Department of Radiology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
Ann Surg. 2004 May;239(5):651-7; discussion 657-9. doi: 10.1097/01.sla.0000124299.57430.ce.
The objectives of this analysis were to define the incidence, natural history, and predictors of neoplasia in pancreatic cysts to determine which patients can safely be observed and which should undergo an operation.
With advancements in imaging technology, cystic lesions of the pancreas are being detected with increased frequency. Many of these lesions are small and asymptomatic, but they may be associated with pancreatitis or have malignant potential. Therefore, the management of these patients is complex, and knowledge of pancreatic cyst natural history and predictors of neoplasia are important.
From January 1995 through December 2002, all radiologic, surgical, and pathology records were reviewed for the presence of pancreatic cysts. In determining natural history, only patients with 2 scans more than 1 month apart at our institution were included. Patients with a clinical history and laboratory evidence of pancreatitis and/or pathologic confirmation of a pseudocyst were excluded. Factors analyzed as potential predictors of neoplasia included age, gender, cyst size, and symptoms. Serous cystadenomas, solid and cystic papillary (Hamoudi) tumors, lymphoepithelial cysts and simple cysts were all benign, whereas mucinous cystic neoplasms, intraductal papillary mucinous neoplasm, cystic neuroendocrine tumors, and cystadenocarcinomas were considered to be premalignant or malignant.
Among 24,039 CT or MR scans, 290 patients (1.2%) had pancreatic cysts, and 168 of these patients (0.7%) had no documentation of pancreatitis. Seventy-nine of these patients with 103 cysts had more than 1 scan with an average interval of 16 months. These cysts increased in size in 19%, did not change in 59% and decreased in 22% of patients. Forty-nine patients underwent surgery for 14 benign (serous cystadenomas = 10, Hamoudi = 2, lymphoepithelial = 1, simple = 1) 25 premalignant (mucinous cystic neoplasm =16, intraductal papillary mucinous neoplasm = 5, neuroendocrine tumors = 4), or 10 malignant (intraductal papillary mucinous neoplasm = 7, cystadenocarcinomas = 3) lesions. Gender and cyst size did not predict neoplasia. However, presence of symptoms predicted premalignant or malignant pathology (60% vs. 23%, P < 0.05), and age over 70 years was associated with malignancy (60% vs. 21%, P < 0.02).
These data suggest that cystic pancreatic neoplasms 1) occur in 0.7% of patients, 2) increase in 19% over 16 months, and 3) are likely (60%) to be malignant in patients older than 70 years. Therefore, we recommend surgical excision for pancreatic cysts that are increasing under observation, symptomatic, or detected radiologically in fit older patients.
本分析的目的是明确胰腺囊肿瘤变的发生率、自然病程及预测因素，以确定哪些患者可安全观察，哪些患者应接受手术。
随着成像技术的进步，胰腺囊性病变的检出率不断增加。这些病变很多较小且无症状，但可能与胰腺炎相关或具有恶变潜能。因此，这些患者的管理较为复杂，了解胰腺囊肿的自然病程及瘤变预测因素很重要。
回顾1995年1月至2002年12月期间所有有关胰腺囊肿的放射学、外科手术及病理学记录。在确定自然病程时，仅纳入在本机构进行了间隔超过1个月的2次扫描的患者。排除有胰腺炎临床病史和实验室证据及/或假性囊肿病理证实的患者。作为瘤变潜在预测因素分析的因素包括年龄、性别、囊肿大小及症状。浆液性囊腺瘤、实性假乳头状（哈穆迪）肿瘤、淋巴上皮囊肿和单纯囊肿均为良性，而黏液性囊性肿瘤、导管内乳头状黏液性肿瘤、囊性神经内分泌肿瘤及囊腺癌被认为是癌前病变或恶性病变。
在24039次CT或MR扫描中，290例患者（1.2%）有胰腺囊肿，其中168例患者（0.7%）无胰腺炎记录。这些患者中有79例103个囊肿进行了1次以上扫描，平均间隔16个月。这些囊肿在19%的患者中增大，59%的患者无变化，22%的患者缩小。49例患者因14个良性病变（浆液性囊腺瘤 = 10个，哈穆迪瘤 = 2个，淋巴上皮瘤 = 1个，单纯囊肿 = 1个）、25个癌前病变（黏液性囊性肿瘤 = 16个，导管内乳头状黏液性肿瘤 = 5个，神经内分泌肿瘤 = 4个）或10个恶性病变（导管内乳头状黏液性肿瘤 = 7个，囊腺癌 = 3个）接受手术。性别和囊肿大小不能预测瘤变。然而，有症状可预测癌前或恶性病理（60%对23%，P < 0.05），70岁以上患者与恶性病变相关（60%对21%，P < 0.02）。
这些数据表明，胰腺囊性肿瘤1）在0.7%的患者中出现，2）在16个月内19%增大，3）在70岁以上患者中很可能（60%）为恶性。因此，我们建议对观察期间增大、有症状或在健康老年患者中经放射学检查发现的胰腺囊肿进行手术切除。
