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Ann Surg. 2019 Jul 24. doi: 10.1097/SLA.0000000000003508. [Epub ahead of print]

Reappraisal of a 2-Cm Cut-Off Size for the Management of Cystic Pancreatic Neuroendocrine Neoplasms: A Multicenter International Study.

Author information

1
General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
2
Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Germany.
3
Department of General, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Germany.
4
Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
5
Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
6
Pancreatic Surgery, IRCCS San Raffaele Hospital, University "Vita e Salute", Milano, Italy.
7
Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD.
8
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
9
Hospices Civils de Lyon & Lyon Sud Faculty of Medicine, UCBL1, E. Herriot Hospital, Department of Digestive Surgery, Lyon, France.
10
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
11
Department of Digestive, Pancreatic and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.
12
Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.

Abstract

MINI: The characteristics of cystic pancreatic neuroendocrine neoplasms (cPanNENs) are largely unknown, and their clinical management remains unclear; specifically, an observational strategy for asymptomatic cPanNENs ≤2 cm has been proposed by recent guidelines, but evidence is scarce and limited to single institutional series. In this international cohort study of 263 resected cPanNENs from 16 institutions worldwide, a preoperative size >2 cm was independently associated with aggressive behavior both in the whole cohort and in the subset of asymptomatic patients; notably, only 1 of 61 asymptomatic cPanNENs ≤2 cm was aggressive. Based on these results, a watch-and-wait policy for sporadic asymptomatic cPanNENs ≤2 cm seems justified and safe.

OBJECTIVE:

The aim of this study was to characterize an international cohort of resected cystic pancreatic neuroendocrine neoplasms (cPanNENs) and identify preoperative predictors of aggressive behavior.

BACKGROUND:

The characteristics of cPanNENs are unknown and their clinical management remains unclear. An observational strategy for asymptomatic cPanNENs ≤2 cm has been proposed by recent guidelines, but evidence is scarce and limited to single-institutional series.

METHODS:

Resected cPanNENs (1995-2017) from 16 institutions worldwide were included. Solid lesions (>50% solid component), functional tumors, and MEN-1 patients were excluded. Aggressiveness was defined as lymph node (LN) involvement, G3 grading, distant metastases, and/or recurrence.

RESULTS:

Overall, 263 resected cPanNENs were included, among which 177 (63.5%) were >2 cm preoperatively. A preoperative diagnosis of cPanNEN was established in 162 cases (61.6%) and was more frequent when patients underwent endoscopic ultrasound [EUS, odds ratio (OR) 2.69, 95% confidence interval (CI) 1.52-4.77] and somatostatin-receptor imaging (OR 3.681, 95% CI 1.809-7.490), and for those managed in specialized institutions (OR 3.12, 95% CI 1.57-6.21). Forty-one cPanNENs (15.6%) were considered aggressive. In the whole cohort, LN involvement on imaging, age >65 years, preoperative size >2 cm, and pancreatic duct dilation were independently associated with aggressive behavior. In asymptomatic patients, older age and a preoperative size >2 cm remained independently associated with aggressiveness. Only 1 of 61 asymptomatic cPanNENs ≤2 cm displayed an aggressive behavior.

CONCLUSIONS:

The diagnostic accuracy of cPanNENs is increased by the use of EUS and somatostatin-receptor imaging and is higher in specialized institutions. Preoperative size >2 cm is independently associated with aggressive behavior. Consequently, a watch-and-wait policy for sporadic asymptomatic cPanNENs ≤2 cm seems justified and safe for most patients.

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